A middle-aged man with volume overload, diabetes and elevated transferrin saturation. An elderly woman with severe tricuspid regurgitation, worsening abdominal bloating and dyspnea on exertion. An elderly man with left ventricular hypertrophy, carpal tunnel syndrome and hypotension despite guideline-directed medical therapy.

These are just a few of the clinical scenarios where multimodality cardiovascular imaging plays an increasingly vital role in diagnosis, patient management and procedural planning. For fellows, the growth in advanced imaging continues to open promising new career trajectories; however, these opportunities require a necessary shift in training.

Our new generation must learn both how to effectively select an ever-expanding array of sophisticated imaging modalities as well as develop the skills to optimally interpret and communicate their findings. Together, these new capabilities will drive better outcomes for patients with cardiovascular disease.

The Many Faces of Multimodality Imaging

For decades, echocardiography and nuclear imaging techniques have been central to evaluating patients with suspected cardiovascular disease. Clinical echocardiography dates to the 1950s, while stress testing with nuclear myocardial perfusion imaging has been a cornerstone of chest pain evaluation since the 1970s.^1-3

Today, multimodality imaging has expanded to include cardiac CT, cardiac MRI and an ever-growing armamentarium of nuclear radiotracers. This evolution parallels advances in structural interventional cardiology and heart failure, where advanced imaging is essential for preprocedure planning and assessment of various etiologies of nonischemic cardiomyopathies such as amyloidosis and sarcoidosis. Simultaneously, operational efficiency demands thoughtful use of stress testing and coronary CT angiography for expeditious evaluation of patients with acute chest pain.⁴

Training in Multimodality Imaging

To fully leverage these modalities, training must evolve. For noncardiac imagers, whether general cardiologists or subspecialists, a baseline familiarity with various modalities, including the indications, contraindications, strengths and limitations, is crucial to ensure appropriate test selection for the right patient in the right clinical context. There is a growing need for cardiologists with advanced cardiac imaging expertise who can not only interpret the expanding array of imaging modalities but also serve as consultants to guide clinicians in this increasingly complex test selection process.

The Core Cardiovascular Training Statement (COCATS) 4 training documents for Task Forces 4 to 8 provide guidance for multimodality imaging training within the context of general cardiovascular disease training. These documents focus on a baseline level of training for the general cardiologist (Levels I and II) and cover competencies within echocardiography, nuclear cardiology, cardiac CT and cardiac MR.⁵

While COCATS 4 provides guidance for basic training, the specific requirements for cardiovascular disease fellowships have been set forth by the Accreditation Council for Graduate Medical Education (ACGME). Completion of these requirements is necessary for trainees to sit for the board examination in cardiology, administered by the American Board of Internal Medicine (ABIM).

Although largely aligned, differences exist between these frameworks, such as training time requirements across imaging modalities. Importantly, COCATS 4 does not offer a unified competency framework necessary for advanced multimodality imagers with respect to gaining knowledge and skills across all four main imaging modalities.

In November 2025, the ACC, in collaboration with the AHA and major imaging societies, published an Advanced Training Statement (ATS) on Advanced Cardiovascular Imaging to address this gap.⁶ This document outlines not only the role of advanced cardiac imagers, but also the key components of training in each modality.

While core education occurs during general cardiovascular disease fellowship, aspiring advanced cardiovascular imagers will need additional training and be expected to have foundational knowledge in all modalities with deeper expertise in one or two areas.

The ACC Imaging Member Section lists advanced imaging training programs and serves as a valuable resource for fellows considering additional training in multimodality imaging. Still, there is a lack of standardization across programs in terms of modalities covered, duration of training and respective application timelines. Although the ATS may aid in standardization, the lack of ACGME accreditation and variability of funding mechanisms across institutions will remain barriers to coordinated adoption of these recommendations.⁷

Additionally, it is not clear at this time how ACGME, ABIM or imaging board certification requirements will incorporate the ATS guidance. Within this variable landscape, mentorship from experienced multimodality cardiovascular imagers and program directors is critical – not only to learn the technical skills of image acquisition and interpretation but also for navigating the diverse training pathways aligned to one's career goals. These individuals can provide guidance regarding the optimal use of elective time during general fellowship, board certification requirements and whether to pursue advanced imaging training.

Different Career Paths

Upon completion of cardiovascular imaging training, fellows encounter a growing array of career opportunities. Large tertiary medical centers may have sufficient volume to support dedicated cardiovascular imagers specializing in specific modalities, while smaller practices often expect cardiologists to interpret imaging alongside other clinical duties.

Moreover, day-to-day workflows will continue to evolve as artificial intelligence facilitates image protocoling, acquisition, interpretation and reporting. Regardless of the ultimate practice environment, demand for expert practitioners with unique skills in advanced imaging modalities will certainly grow. Working side-by-side with multimodality advanced imaging cardiologists during fellowship is critical for trainees to envision a future career path in this relatively new discipline, overcoming a familiarity gap that may dissuade some from pursuing these exciting and expanding roles.

Trainees today can capitalize on these developments by engaging with multimodality imaging during general cardiovascular disease fellowship and by pursuing advanced subspecialty training. Those who do will acquire a valuable skillset they can bring to multidisciplinary cardiovascular teams caring for patients across the disease spectrum. The new ATS on multimodality imaging provides a framework for further evolution of training across these disciplines, complementing efforts within each imaging modality. Now is the time for institutions, programs, and trainees to embrace these growing opportunities.

Interested in imaging? Are you a FIT? Learn about and join these ACC Member Sections and more.

References

1. Feigenbaum H. Evolution of echocardiography. Circulation. 1996;93(7):1321-1327.
2. Zaret BL, Strauss HW, Martin ND, et al.. Noninvasive regional myocardial perfusion with radioactive potassium. Study of patients at rest, with exercise and during angina pectoris. N Engl J Med. 1973;288(16):809-812.
3. Strauss HW, Harrison K, Langan JK, et al. Thallium-201 for myocardial imaging. Relation of thallium-201 to regional myocardial perfusion. Circulation. 1975;51(4):641-645.
4. Cairns C, Kang K. National Hospital Ambulatory Medical Care Survey: 2022 emergency department summary tables. Available here. https://ftp.cdc.gov/pub/Health_Statistics/NCHS/ Dataset_Documentation/NHAMCS/doc22-ed-508.pdf. Accessed 11/21/2025.
5. Halperin JL, Williams ES, Fuster V. COCATS 4 Introduction. JACC. 2015;65(17):1724-1733.
6. Baldassarre LA, Mendes LA, Blankstein R, et al. 2025 ACC/AHA/ASE/ASNC/SCCT/SCMR Advanced Training Statement on Advanced Cardiovascular Imaging. JACC.2026;87(5):570-632.
7. Upadhyay N, Bravo PE, Kulkarni VT. Advanced Imaging Training Statement: A First Step on the Road Toward Standardization. JACC.2026;87(5):633-635.

Clinical Topics: Noninvasive Imaging

Keywords: Cardiology Magazine, ACC Publications, CM-Jul-Aug-2026, Fellows in Training, Multimodal Imaging, Cardiac Imaging Techniques