2017 Advanced Training Statement on Advanced Heart Failure and Transplant Cardiology

Authors:
Jessup M, Drazner MH, Book W, et al.
Citation:
2017 ACC/AHA/HFSA/ISHLT/ACP Advanced Training Statement on Advanced Heart Failure and Transplant Cardiology (Revision of the ACCF/AHA/ACP/HFSA/ISHLT 2010 Clinical Competence Statement on Management of Patients With Advanced Heart Failure and Cardiac Transplant): A Report of the ACC Competency Management Committee. J Am Coll Cardiol 2017;Mar 8:[Epub ahead of print].

The following are key points to remember about this revised Advanced Training Statement on Advanced Heart Failure and Transplant Cardiology (AHFTC):

  1. This Advanced Training Statement addresses the added competencies required of subspecialists in AHFTC for diagnosis and management at a high level of skill of patients with heart failure who may also undergo placement of mechanical circulatory support (MCS) devices or cardiac transplantation.
  2. The training is intended to complement the basic training in heart failure required of all cardiology trainees during the standard 3-year cardiovascular fellowship.
  3. Level III training in advanced heart failure requires robust clinical experiences in both the outpatient and inpatient settings, including the intensive care unit. In each clinical setting, trainees should participate in supervised patient care and act as initial consultant for a portion of the training period with appropriate and timely backup from attending physicians.
  4. Level III training in AHFTC requires competence in right heart catheterization and endomyocardial biopsy, acquired through experiences in the catheterization laboratory. AHFTC trainees must become familiar with the programming and interpretation of data stored in implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT) devices, which can be obtained by device interrogation. Experience in the indications and management of MCS devices providing temporary hemodynamic support of critically ill patients with heart failure is also needed, recognizing that criteria for selection of specific devices may differ.
  5. Trainees should be taught to recognize and initiate management for complications of MCS devices, including thrombosis, stroke, infection, bleeding, and pump malfunction.
  6. All trainees are expected to carry out research and/or engage in scholarly activities during Level III training in AHFTC. Scholarly activity related to heart failure, pulmonary hypertension, MCS, or transplant cardiology may include original clinical, basic science, translational, or interdisciplinary research; quality improvement activities; presentation at institutional, local, and national meetings; and publication of original articles, reviews, chapters, or case reports.
  7. Training requirements in AHFTC address the six general competencies promulgated by the Accreditation Council for Graduate Medical Education (ACGME) and endorsed by the American Board of Internal Medicine (ABIM). These competency domains are Medical Knowledge, Patient Care and Procedural Skills, Practice-Based Learning and Improvement, Systems-Based Practice, Interpersonal and Communication Skills, and Professionalism.
  8. An essential component of training an AHFTC practitioner is understanding of the indications for, contraindications to, and complications of procedures commonly performed in patients with advanced heart failure, including ventricular assist devices and cardiac transplantation. Each trainee should maintain a record that documents the indications, outcomes, and diagnoses associated with procedures they performed or attempted, along with the name of the supervising faculty member.
  9. The AHFTC trainee should know the pathophysiology of heart failure at the molecular, cellular, and organ levels, including the roles of neurohormonal activation and ventricular remodeling in disease progression.
  10. The AHFTC trainee should learn how to direct the outpatient evaluation of patients with recently identified heart failure to identify specific etiologies and understand the role of genetic testing. Various tools are available to assess patients with heart failure, including the clinical history and physical examination, multimarker risk scores, quality of life assessments, natriuretic peptide testing, stress testing including cardiopulmonary stress tests, and noninvasive imaging techniques. Trainees should become comfortable with each of these modalities and know their strengths and limitations.
  11. The trainee must acquire the medical knowledge and clinical skills to identify candidates for temporary and/or durable MCS, including those needing biventricular support.
  12. The major goal of outpatient management of a heart transplant recipient is to maximize benefit and minimize toxicity of immunosuppression. Level III trainees should become familiar with strategies to individualize immunosuppression based on the patient’s risk of rejection and infection, as guided by a history of rejection or infection, medication tolerance, antibody sensitization, compliance, presence of transplant vasculopathy, malignancy, peripheral blood gene-expression profiling, and results of T-cell immune function assays.
  13. According to the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Guideline for the Management of Heart Failure, palliative and supportive care is useful for patients with symptomatic heart failure to improve quality of life. Discussions focused on shared decision making provide patients, families, and clinicians the opportunity to work together to make decisions about care and choose treatment options that are in line with the patient’s values, goals, and preferences.

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