Europace

Europace 2009 11(Supplement 3):iii1-iii26; doi:10.1093/europace/eup215

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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org.

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Core Curriculum

Core curriculum for the heart rhythm specialist

Jose L. Merino, (Spain)^*, Fernando Arribas, (Spain), Giovanni Luca Botto, (Italy), Heikki Huikuri, (Finland), Lars I. Kraemer, (Germany), Cecilia Linde, (Sweden), John M. Morgan, (UK), Martin Schalij, (The Netherlands), Emmanuel Simantirakis, (Greece), Christian Wolpert, (Germany), Marie-Christine Villard, (France) , Julie Poirey, (France) , Svya Karaim-Fanchon, (France) , Keren Deront, (France)  on behalf of the 2005–2007 Accreditation Committee of the European Heart Rhythm Association

2005–2007 Accreditation Committee, European Heart Rhythm Association, European Society of Cardiology

Manuscript submitted 11 May 2009. Accepted after revision 14 July 2009.

^* Corresponding author. Arrhythmia Research Unit, Hospital Universitario La Paz, P. Castellana 261, 28046 Madrid, Spain. Tel: +34 619 97 4115, Fax: +34 917277564, Email: jlmerino{at}arritmias.net

	Abstract

Top Abstract Introduction Definitions and glossary Summarized syllabus General learning objectives Training requirements and plan Training centre and trainer... Training assessment Continuous medical education and... Author's funding by private... References

 
Heart rhythm (HR) management is rapidly developing as a subspecialty within cardiology and it is imperative to promote and ensure sufficient and homogeneous training and qualification among professionals in Europe. This encouraged the European Society of Cardiology, through the European Heart Rhythm Association (EHRA), to organize a European Core Curriculum for the HR specialist through the following: definition of the scope of the HR speciality (Syllabus), development of minimum standards and objectives for training in HR management (Curriculum), development of a model to certify HR professionals and teaching units (Accreditation), and development of a Registry for European HR accredited professionals and teaching units and their activity (Registries). The duration of the training period should be of a minimum of 2 years following general cardiology training. During this period, the trainee must develop the required knowledge, practical skills, behaviours, and attitudes to manage HR patients. The trainee must be involved in a minimum number of different procedures and achieve specified levels of competence. The training centre should be integrated within a full-service cardiology department. Assessment of the trainee and the training programmes should include reports by the training programme supervisor and the national society HR organizations, a logbook of procedures, written examinations, and assessment of professionalism. The EHRA presently requires the trainee to pass the EHRA accreditation exams (invasive EP and cardiac pacing and ICDs). Continuous learning and practice are required to maintain standards and practice because substantial changes may occur in clinical practice or the health-care environment.

Key Words: Accreditation, Arrhythmia, Curriculum, Education, Electrophysiology, Heart rhythm

	Introduction

Top Abstract Introduction Definitions and glossary Summarized syllabus General learning objectives Training requirements and plan Training centre and trainer... Training assessment Continuous medical education and... Author's funding by private... References

 
Heart rhythm (HR) management is rapidly developing as a subspecialty within cardiology that is devoted to the diagnosis and the treatment of cardiac rhythm disorders, including invasive evaluation of their mechanisms, controlled destruction of arrhythmogenic myocardium by percutaneous catheters, and implantation of cardiac rhythm management devices. Catheter ablation is the therapy of choice for most supraventricular tachycardias. More than 50 000 interventions are performed every year in Europe.¹ Device implantation for arrhythmia treatment, sudden death prevention, and cardiac resynchronization are practiced regularly nowadays, and are performed in more than 200 000 patients in Europe per year.¹ The increase in the indications and the number of all of these procedures depicts the present scenario by emerging indications, an increasing number of invasive procedures, and the establishment of new practising units and professionals. Nevertheless, these procedures require cardiologists with comprehensive knowledge of HR disorders and who are trained in cardiovascular catheter manipulation, heart electrical signal recording and interpretation, and device implantation and follow-up to ensure both patient's safety and quality. Thus, it appears to be imperative to promote and ensure sufficient and homogeneous training and qualification in HR management amongst these professionals in Europe.

In addition, the European Council of Ministers adopted a recommendation on the development and implementation of systems on 30 September 1997 to improve the quality and homogeneity of Health Care Services. The recommendation stated that quality systems must be publicly controlled through objective external evaluation by independent organizations. Although training and accreditation programmes are conducted both nationally and regionally, coordination at the European level is needed for two reasons in particular:

1. Transnational cooperation is not well organized resulting in the duplication of work and an inability to compare work implemented in different countries due to unnecessary methodological variations.
   
2. The development of a uniform and a consistent set of standards will provide a good tool to facilitate qualified health services and ensure free movement across barriers, both for professionals and for patients.
   

These two reasons are even more relevant nowadays due to the development experienced by the European health care systems, the increasing national integration of the European Union, and the challenges currently arising, such as increased management autonomy, intercountry invoicing, and competition between Health Care centres.

These reasons supported the commitment of the European Society of Cardiology (ESC), through the European Heart Rhythm Association (EHRA), in organizing such a European system together with the Registries of European certified units, professionals, and activities. A European programme in this field will be of utmost interest and will represent a harmonized and uniform way to ensure high standards of excellence. Thus, the general aim is to organize a European Core Curriculum for the HR specialist associated with an Accreditation System to certify professional practice through the following objectives:

1. Definition of the scope of the HR speciality (Syllabus)
   
2. Development of a minimum standards and objectives recommendation for training in HR management (Core Curriculum)
   
3. Development of an Accreditation model for European HR professionals and teaching units (Accreditation)
   
4. Development of a Registry for European HR accredited professionals and teaching units and its activity (Registries)
   

This document describes the EHRA system.

The ESC, the EBSC, and the EHRA
The European Society of Cardiology (ESC) is a private, non-profit making organization. The goals of the ESC ‘to foster the development of cardiology, to further scientific exchanges, to encourage personal contacts, and to establish standards of training for cardiologists and those who work in the field of cardiovascular disease’ are clearly defined in the original statutes. The ESC, after 50 years of existence, has now broadened its goals and is ‘dedicated to improving the quality of life of the European population by reducing the impact of cardiovascular disease’. The society is comprised of both European and foreign cardiologists and other professionals related to cardiovascular diseases. The Chairman and the Board of Directors are selected biennially. The ESC does not receive public funds and is neither legislative nor authoritative.

The Heart Rhythm Association (EHRA) is a registered branch of the ESC, which specifically deals with aspects related to cardiac electrical physiology and HR problems. Its general aim is to foster the development of specific areas of expertise in HR and to improve collaboration between the common interests of different Working Groups in certain areas. The goals of the EHRA ‘to improve the quality of life of the European population by reducing the impact of cardiac arrhythmias and reduce sudden cardiac death’ are defined in the statutes. The EHRA maintains the links and cohesion with the entire ESC group, while allowing a more specific and a more fruitful development of its particular area of expertise.

The EHRA is integrated in the EBSC (European Board for the Specialty of Cardiology) Taskforce on Subspecialty Accreditation. The EBSC is a composite of the ESC and the UEMS (Union of the European Medical Specialists), which is linked to the European Commission. The mission of this task force is defining and promoting standards, requirements, and procedures in subspecialty accreditation in cardiology. At present, the following subspecialties under evaluation for recognition by this task force are acute cardiac care, echocardiography, HR management, interventional cardiology, nuclear cardiology, and cardiovascular magnetic resonance.²

	Definitions and glossary

Top Abstract Introduction Definitions and glossary Summarized syllabus General learning objectives Training requirements and plan Training centre and trainer... Training assessment Continuous medical education and... Author's funding by private... References

 
Accreditation
Accreditation is a process resulting in a diploma/certificate indicating proficiency. This applies to individuals, institutions, and laboratories. Different terms have been often used and confused with accreditation including:

–Accreditation: signifies granting credit or recognition, or proving certitude. It is voluntary and motivational, and its objective is the improvement of quality. The standards measured are optimal. It is performed in health centres, which already have the appropriate authorization from the corresponding official organization to carry out a certain activity and, therefore, are already operational.

–Authorization: signifies granting permission. It is obligatory and it is always performed prior to opening a specific programme. Its purpose is therefore legislative, that is to say, to verify compliance with the minimum standard criteria demanded before granting authorization to commence a specific activity.

–Inspection: signifies examining in detail or verifying. It is obligatory and it is implemented to maintain control. Its purpose is supervisory, that is to say, its objective is to check compliance with the criteria demanded by the regulations once a programme is opened.

–Homologation: signifies verifying authoritatively compliance with determined specifications or properties. It can be voluntary or obligatory. The objective is to guarantee that the product complies with previously defined specifications. The purpose is homologous. Minimum standards must be measured. It may or may not be operational.

Certification
Certification is not used in this document. It is not equivalent to accreditation; it involves passing an assessment of knowledge, which is only a part of an accreditation process. Assessments of knowledge demonstrate objective competency in the theory within a field.

Curriculum
A curriculum is a formal education plan for a training programme that intended to establish specific learning outcomes.

Syllabus
A syllabus is a listing of subject matters that are covered in a training programme.

Logbook
A logbook is a record of the trainee's practical experience.

Heart rhythm specialist
A cardiologist with specific knowledge, training, skills, and attitudes for the study, management, research, and teaching of the HR disorders.

Cardiac electrophysiology
Cardiac electrophysiology (EP) is the field of cardiology related to the study and management of HR physiology and disorders. It includes both invasive and non-invasive techniques. Invasive Cardiac EP is the discipline that involves the study, diagnosis, treatment, and prevention of cardiac arrhythmias through recording electrical activity, stimulation, and the controlled creation of endocardic and epicardiac lesions in the heart and its principal vessels through electro-catheters, which are generally introduced by the percutaneous vascular route. Knowledge of the management of HR implantable devices, as one of the diverse diagnostic and therapeutic approaches for HR disorder management, is also required for proficiency in this specialty.

Heart rhythm implantable devices: pacemakers, defibrillators, and others
Heart rhythm implantable devices are devices that are designed for implantation in the human body for the study, diagnosis, prevention, or management of HR disorders. The most frequent HR implantable devices are pacemakers (PMs), implantable cardioverter–defibrillators (ICDs), and devices for cardiac resynchronization therapy (CRT). Proficiency in this discipline requires also a basic knowledge about invasive and non-invasive cardiac EP.

Organizations
EBSC is the European Board for the Speciality of Cardiology.

EBAC is the European Board for Accreditation in Cardiology.

UEMS-CS is the Union Européenne des Médecins Spécialistes-Cardiology Section.

	Summarized syllabus

Top Abstract Introduction Definitions and glossary Summarized syllabus General learning objectives Training requirements and plan Training centre and trainer... Training assessment Continuous medical education and... Author's funding by private... References

 
Heart rhythm management is a rapidly developing field with the most extensive and complex knowledge base in cardiology. This has been recognized by some organizations, such as the American Board of Internal Medicine, which considers HR management to be sufficient in itself to constitute a subspecialty, a consideration that, until a short time ago, was not held by any other discipline in cardiology.³ In addition, the cardiologist, who is a subspecialist in this area, must also understand other techniques and related areas, many of which are necessary to undertake and interpret the procedures, and others without which their ability to take decisions would be limited. The Subspecialty Syllabus is the comprehensive index of the present knowledge in the HR Subspecialty, which includes knowledge in both Invasive Cardiac EP and Cardiac Rhythm Implantable Devices. Development of such a comprehensive knowledge base required by the HR specialist is warranted. However, it must be recognized that such a syllabus should be considered just as a summary because it is unrealistic to detail all the possible aspects and variants related to the HR field reported in the scientific literature. This is especially true since knowledge in this field is developing rapidly and both major and minor advances are regularly published in peer-reviewed scientific journals. Therefore, for formal aspects, the knowledge base of the HR subspecialty will consider all data and information related to it that has been made public and are currently available as published work in international peer-reviewed journals, either in the paper or the electronic format. For a full list of peer-review journals, please refer to the major scientific citation indexes, such as Current Contents© or Medline©. Nevertheless, a summarized syllabus for the HR specialist, in general, and for Invasive Cardiac EP and HR Implantable Devices, in particular, has a practical interest and is presented in this section.

Syllabus for the heart rhythm specialist

1. Normal and abnormal anatomy of the heart and the conduction system
   
2. Normal and abnormal general physiology and heart EP, including ion channels, cellular EP, autonomous system influences, and the basic mechanisms of rhythm disorders, syncope, and sudden death
   
3. Arrhythmic disorders (epidemiology, genetics, pathophysiology, clinical features and diagnosis, prognosis and risk evaluation, treatment, prevention, and ESC Guidelines):

   3.1 Sinus node and atrial impulse formation and conduction disorders
   

   3.2 AV nodal and His-Purkinje conduction disorders
   

   3.3 Atrial and thoracic vein ectopy and tachycardias
   

   3.4 Atrial flutter
   

   3.5 Atrial fibrillation
   

   3.6 Junctional and AV node ectopy and tachycardias
   

   3.7 Accessory pathway mediated tachycardias
   

   3.8 Ventricular ectopy and tachycardias
   

   3.9 Ventricular fibrillation
   

   3.10 Autonomic disorders (carotid sinus hypersensitivity, neurocardiogenic syncope, and other)
   

   
   
4. Arrhythmogenic diseases and syndromes (epidemiology, genetics, pathophysiology, clinical features and diagnosis, prognosis and risk evaluation, treatment, prevention, and ESC Guidelines):

   4.1 Ischaemic cardiomyopathy
   

   4.2 Non-ischaemic cardiomyopathies:

   4.2.1 Idiopathic dilated cardiomyopathies
   

   4.2.2 Hypertrophic cardiomyopathies
   

   4.2.3 Right ventricular arrhythmogenic cardiomyopathies
   

   4.2.4 Neuromuscular cardiomyopathies
   

   4.2.5 Valvular-related cardiomyopathies
   

   4.2.6 Congenital diseases
   

   4.2.7 Other (Chagas disease, etc.)
   

   
   

   4.3 Channelopaties and other inherited syndromes:

   4.3.1 Long and short QT syndromes
   

   4.3.2 Brugada syndromes
   

   4.3.3 Catecholaminergic polymorphic ventricular tachycardia
   

   4.3.4 Congenital conduction disorders
   

   4.3.5 Other
   

   
   

   4.4 Other situations leading to rhythm disorders
   

   
   
5. Diagnostic procedures and techniques in Heart Rhythmology and Clinical EP (rationale, materials and equipment, techniques and procedures, complications, result interpretation, indications and contraindications, and ESC Guidelines):

   5.1 Clinical evaluation (history and physical examination)
   

   5.2 Electrocardiography (ECG):

   5.2.1 Conventional 12-lead ECG
   

   5.2.2 ECG monitoring (Holter, event monitoring, implantable event, and loop monitoring)
   

   5.2.3 Heart rate variability and baroreflex sensitivity
   

   5.2.4 Signal-averaged ECG
   

   5.2.5 T-wave and micro-T-wave alternants
   

   5.2.6 Body surface mapping
   

   
   

   5.3 ECG-pharmacological tests:

   5.3.1 Type I drugs for His-Purkinje system challenge
   

   5.3.2 Type I drugs for Brugada ECG unmasking
   

   5.3.3 Adrenaline for congenital long QT syndrome unmasking
   

   5.3.4 Adrenaline/atropine for sinus node dysfunction
   

   5.3.5 Adenosine/ATP for sinus node and AV node dysfunction
   

   5.3.6 Other
   

   
   

   5.4 Exercise tests
   

   5.5 General knowledge in imaging techniques [fluoroscopy, echocardiography, magnetic resonance imaging (MRI), computed tomography (CT), nuclear imaging, angiograms, and other]
   

   5.6 Autonomic nervous system evaluation:

   5.6.1 Carotid sinus massage
   

   5.6.2 Supine to orthostatism for orthostatic hypotension evaluation
   

   5.6.3 Tilt testing
   

   5.6.4 Other
   

   
   

   5.7 Transoesophageal electrical evaluation
   

   5.8 Invasive EP studies
   

   5.9 Other
   

   
   
6. Therapies in heart rhythmology and Clinical EP (rationale, material and equipment, techniques and procedures, side-effects and complications, results, indications and contraindications, and ESC Guidelines):

   6.1 Physical and autonomous system manoeuvres
   

   6.2 Resuscitation and life support
   

   6.3 Drugs with antiarrhythmic effects
   

   6.4 Drugs for associated rhythm problems (anticoagulants, vasodilatators, and other)
   

   6.5 Transient electrical stimulation:

   6.5.1 Transcutaneous
   

   6.5.2 Transoesophageal
   

   6.5.3 Intracardiac percutaneous
   

   
   

   6.6 Cardioversion and defibrillation
   

   6.7 Invasive EP guided therapies
   

   6.8 Percutaneous catheter ablation
   

   6.9 Implantable HR devices (PMs, ICDs, CRTs, and other)
   

   6.10 General knowledge of cardiac and antiarrhythmic surgery
   

   6.11 Other
   

   
   
7. Professional, legal, ethical, and socioeconomical aspects
   

Specific syllabus for invasive cardiac electrophysiology
This syllabus includes the comprehensive knowledge of the areas included in the summarized syllabus for the HR specialist, but with specific knowledge in invasive cardiac EP, as follows:

1. EP laboratory equipment (fluoroscopy, catheters, sheaths, EP signal recording systems, navigation systems, programmed electrical stimulation systems, and other)
   
2. Catheter placement techniques including cardiac access (transvenous, pericardial, and other), guiding means (fluoroscopic or non-fluoroscopic, manual or remote navigation, and other), and other
   
3. ECG and EP signals (bipolar/unipolar, filters, voltage/timing/morphology, and other)
   
4. Programmed electrical stimulation techniques (pulse width/amplitude, unipolar/bipolar, continuous/extrastimulus stimulation, atrial/ventricular/other location stimulation, pacing algorithms, and other) and pharmacological tests and modulation
   
5. Angiography of cardiac chambers and vascular structures, such as the pulmonary veins
   
6. Basic EP principles (intervals, refractoriness, conduction velocity, block/gap, and other)
   
7. Basic arrhythmia mechanisms (macroreentry, microreentry, automatism, triggered activity, reflection, and other)
   
8. Impulse formation and conduction within the heart (sinus function, sinoatrial conduction, atrial conduction and refractoriness, AV nodal and His Purkinje physiology, ventricular conduction and refractoriness, and other)
   
9. ECG and EP (cardiac activation, responses to electrical stimulation and to drug administration, EP diagnosis, and other) of normal HR and electrical impulse conduction
   
10. ECG and EP (induction, cardiac activation, responses to electrical stimulation and to drug administration, cardiac activation, EP diagnosis, and other) of the different types and variants of sinus and AV node and His-Purkinje impulse formation and conduction defects including sick sinus syndrome, AV block, intraventricular conduction blocks, and autonomous system mediated disorders (carotid sinus hypersensitivity, neurocardiogenic syndromes, and other)
    
11. ECG and EP (induction, termination, cardiac activation, responses to electrical stimulation and to drug administration, EP diagnosis, and other) of the different types and variants of sinus node and atrial arrhythmias, including atrial ectopy, atrial escape and accelerated rhythms, sinus node and atrial tachycardias, atrial flutters, and atrial fibrillation
    
12. ECG and EP (induction, termination, cardiac activation, responses to electrical stimulation and to drug administration, EP diagnosis, and other) of the different types and variants of junctional arrhythmias, including junctional ectopy, junctional escape and accelerated rhythms, and junctional tachycardias
    
13. ECG and EP (induction, termination, cardiac activation, responses to electrical stimulation and to drug administration, EP diagnosis, and other) of the different types and variants of ventricular arrhythmias, including ventricular ectopy, ventricular escape and accelerated rhythms, ventricular tachycardias, ventricular flutter, and ventricular fibrillation
    
14. ECG and EP (induction, termination, cardiac activation, responses to electrical stimulation and to drug administration, EP diagnosis, and other) of the different types and variants of AV accessory pathways and AV accessory pathways mediated arrhythmias, including ectopy, escape and accelerated rhythms, and tachycardias
    
15. ECG and EP (induction, termination, cardiac activation, responses to electrical stimulation and to drug administration, EP diagnosis, and other) of the different types and variants of inherited rhythm disorders (long and short QT syndromes, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, and other)
    
16. Ablation techniques (catheters, energies, biophysics, mapping, anatomical substrates, success predictors, and other) of the different rhythm disorders previously stated
    
17. Complications and adverse effects of EP studies and ablation: pathophysiology, diagnosis, prevention, and management
    
18. Professional, legal, ethical, and socioeconomical issues
    

Specific syllabus for heart rhythm implantable devices
This syllabus includes the basic knowledge of the areas included in the summarized syllabus for the HR specialist, but with specific knowledge of HR implantable devices (Cardiac Pacing, ICDs, and other), as follows:

1. Historical perspectives of HR implantable devices
   
2. Conventional and non-conventional indications of HR implantable devices (bradiarrhytmias, tachycarrhythmias, heart failure and cardiomyopathies, sleep apnoea syndrome, and other)
   
3. Electricity and electronics related to physic laws, waveforms, parameters, measurements, and units
   
4. Haemodynamics and physiology of cardiac pacing and defibrillation
   
5. HR implantable devices and components:

   5.1 Models and modes (international codes, other)
   

   5.2 Generators (battery, capacitors, circuits, and other)
   

   5.3 Leads and arrays (material, structure, type, electrodes, coils, connector/adapters, and other)
   

   5.4 Sensors
   

   5.5 Ancillary materials (sheaths, guidewires, and other)
   

   
   
6. Implantation and replacement/extraction techniques (surgery, lead implantation/replacement techniques, and other)
   
7. Fluoroscopy, angiography, and other navigation techniques
   
8. Electrogrammes, markers, intervals, Holter features, and other storage and diagnosis capabilities
   
9. Device testing at implantation (pacing and sensing measurements and parameters, arrhythmia induction and termination, and other)
   
10. Rhythm and device detection programming:

    10.1 Detection zones
    

    10.2 Refractory and blanking periods
    

    10.3 Tachycardia discrimination (single and dual chambers)
    

    10.4 AV synchrony, hysteresis, automatic mode change
    

    10.5 Rhythm and device problem detection alarms
    

    
    
11. Rhythm therapy programming:

    11.1 Cardioversion and defibrillation (modes, parameters, algorithms and automatisms, and other)
    

    11.2 Antitachycardia pacing (modes, parameters, algorithms and automatisms, and other)
    

    11.3 Antibradicardia pacing (modes, parameters, algorithms and automatisms, and other)
    

    11.4 Haemodynamic and resynchronization pacing (modes, parameters, algorithms and automatisms, and other)
    

    
    
12. Follow-up:

    12.1 Longevity estimation and general and interval recommendations
    

    12.2 Device parameters to measure (sensing, pacing, defibrillation, lead integrity, battery life, arrhythmia episodes, and other)
    

    12.3 Normal and abnormal ECG at follow-up in HR device recipients
    

    12.4 Memory loop/channels markers
    

    12.5 Invasive and non-invasive evaluation of pacing, cardioversion-defibrillation, and cardiac synchronization
    

    12.6 Telemonitoring
    

    
    
13. Pathophysiology, diagnosis, prevention, and management of complication:

    13.1 Related to implantation and surgical techniques (pneumothorax, bleeding, thrombosis, infection, and other)
    

    13.2 Related to electrode, arrays, or generator dysfunction (connection, dislocation, isolation defects, conductor defects, and other)
    

    13.3 Related to inappropriate model selection and programming (PM syndrome, arrhythmogenesis, and other)
    

    13.4 Related to malfunction (over or undersensing, pacing, defibrillation, electrical and magnetical interferences, and other)
    

    13.5 Related to drug or other device interactions
    

    13.6 Related to psychological problems
    

    
    
14. Professional, legal, ethical, and socioeconomical issues
    

	General learning objectives

Top Abstract Introduction Definitions and glossary Summarized syllabus General learning objectives Training requirements and plan Training centre and trainer... Training assessment Continuous medical education and... Author's funding by private... References

 
Individual training in HR management requires the basic skills of a good physician. He/she should have a solid background in all aspects of general medicine, which can provide the basis for specialized arrhythmia care. Cardiac arrhythmia management is recognized as a particularly challenging field of expertise. The complexity of arrhythmia mechanisms and the consequent complexity of understanding them and the management options are challenging. This justifies the dedicated training period following general cardiology training.⁴ At the same time, individuals in the field require a sound understanding of the research principles and mechanisms, including study design and statistical principles. In addition, a thorough knowledge of the principles of clinical ethics and clinical and research governance is required. Patients with cardiac arrhythmias are a particularly vulnerable group and understanding cardiac arrhythmia abnormality can be a significant challenge for the lay person. Thus, development of patient communication and ‘people’ skills is highly important. Finally, administration of clinical practices requires a broad set of administrative skills. The individual responsible for service management needs to equip him/herself with an understanding of the basic management principles, including management skills, such as the ability to successfully ‘people-manage’, write business plans, perform audits, negotiate the purchase of consumables and equipment, and undertake appraisal.

The knowledge that trainees require to become competent in the management of patients with HR disorders is defined in the Core Syllabus section. However, the Core Curriculum needs to establish what the trainee should be able to do at the end of the training period, that is, the general learning objectives. This section presents tables (Tables 1–12) of the main learning objectives to achieve in the different areas of HR management together with the knowledge, the practical skills, the behaviour, and the attitudes the trainee should have achieved at the end of the training period.

View this table: [in this window] [in a new window]   Table 1 Anatomy of the heart and the conduction system

 

View this table: [in this window] [in a new window]   Table 2 General physiology and heart electrophysiology

 

View this table: [in this window] [in a new window]   Table 3 Diagnostic procedures and techniques: general

 

View this table: [in this window] [in a new window]   Table 4 Diagnostic procedures and techniques: invasive cardiac electrophysiology

 

View this table: [in this window] [in a new window]   Table 5 Therapies: general

 

View this table: [in this window] [in a new window]   Table 6 Therapies: catheter ablation

 

View this table: [in this window] [in a new window]   Table 7 Therapies: implantable devices: pacemakers

 

View this table: [in this window] [in a new window]   Table 8 Therapies: implantable devices (implantable cardioverter-defibrillators)

 

View this table: [in this window] [in a new window]   Table 9 Therapies: implantable devices (multisite ventricular pacing for resynchronization)

 

View this table: [in this window] [in a new window]   Table 10 Arrhythmic disorders

 

View this table: [in this window] [in a new window]   Table 11 Arrhythmogenic diseases and syndromes

 

View this table: [in this window] [in a new window]   Table 12 Professional, legal, and socioeconomical aspects

 

	Training requirements and plan

Top Abstract Introduction Definitions and glossary Summarized syllabus General learning objectives Training requirements and plan Training centre and trainer... Training assessment Continuous medical education and... Author's funding by private... References

 
This section details the minimal requirements of the training programme for HR specialists. Following this training programme, the trainee will entitle recognition of theoretical and practical competency in invasive EP and HR management device implantations and follow-up. At the end of the training programme, the trainee should be able to treat independently patients with HR disorders. The duration of training, the training plan, and the certification process are described in this section.

Training duration
Due to the complexity of treating patients with HR disorders and the difficulty of performing catheter ablation procedures and device implantations independently as the first operator, the duration of the training period should be for a minimum of 2 years. During this period, the trainee must be involved in all aspects of HR management, including the research and educational activities of the teaching department. The trainee should not only fulfil the criteria concerning the procedure numbers, but should also undergo a final evaluation. Such an evaluation has been developed by the EHRA, which presently requires the trainee to take and pass the EHRA accreditation exams (invasive EP and cardiac pacing and ICDs) in order register as a HR specialist in this association. Finally, the programme director should provide a written statement concerning the ability of the trainee to treat patients with cardiac arrhythmias at the end of the training period. Assessment of competency should be closely monitored by the programme director and the teachers in order to evaluate the progress of the trainee during the training period.

Trainee requirements
The minimum education, training, experience, and skills necessary to perform HR procedures are designed for trained or trainee cardiologists. A cardiology background is necessary not only to master the technical aspects, but also to verify the indications and contraindications, to conduct investigations, and to give an accurate and comprehensive interpretation of the clinical data. Therefore, the trainee should be a registered cardiologist or should fulfil the requirements of a general cardiologist set in the core curriculum of the ESC in order to enter the programme accordingly. However, because official recognition as a cardiology specialist is delayed several years after the end of cardiology training in some European countries, trainees who finalize their training programme in HR management and who will become a registered cardiologist in less than 5 years after that date will be recognized as registered HR specialists by the EHRA.

Training plan
The trainee should follow a structured teaching programme and the learning objectives detailed in the previous section. The teaching program should include the development of appropriate behaviours and attitudes together with the knowledge and manual skills of the catheter, recording techniques, and the different systems used in the treatment of patients with HR problems. The programme must be comprehensive and completion of the training in one centre is recommended. However, if a centre is not able to develop a complete teaching programme, it should work with other centres to complete its lacking activities or to allow the trainee to participate in teaching programmes developed by EHRA or other recognized educational activities. Therefore, more than one centre may be responsible for the teaching programme although each centre is encouraged to develop a structured teaching programme dealing with the management of HR problems. In addition, simulator training should be encouraged prior to entering the programme in order to shorten the learning curve for procedures such as coronary sinus lead placement.

The training plan should include clinical activities and practical training together with theoretical educational activities, and research activities and education. During the training period, trainees should attend and participate in weekly meetings reviewing topics and discussing patients, indications, results, and procedural-related complications. In addition, the trainee should attend at least one official international subspecialty meeting of a scientific society in the field. The trainee must be involved in research activities in the HR field and should present at least one scientific abstract at a national or international meeting in the field during the training period.

During the 2 year training period, the trainee should participate in the HR training programme for at least 80% of the working hours (based on full-time employment). Although in some cases, it may be possible to expand the training period if the participation drops below 80%, this should remain an exception. During the training period, dedication to the different clinical activities should be distributed as follows:

1. Outpatient clinic: 10% of the training period
   
2. Device (ICD, CRT, and PMs) follow-up: 10% of the training period
   
3. Device (ICD, CRT, and PMs) implantations: 10% of the training period
   
4. Invasive EP: 40% of the training period.
   

Based on a 2 year training period (assuming that basic cardiology training is completed), training should be distributed as follows:

Months 1–4
Outpatient clinic
During this period, the trainee will treat patients at the outpatient clinic under close supervision of one of the trainers. It should be a dedicated outpatient clinic dealing mainly with patients with arrhythmias. The indication to refer a patient for catheter ablation or device implantation should be discussed with the trainer.

Device follow-up
During this period, the trainee will learn to perform the technical follow-up of device patients.

Furthermore, the trainee must become familiar with the different devices in the HR department.

Arrhythmia clinic
During this period, the trainee will be responsible for the arrhythmia clinic under close supervision of one of the trainers. Special attention should be paid to the development of the HR clinician. Furthermore, the trainee should become familiar with the psychological effects that an ablation procedure or device implant can have on the patient and the patient's relatives.

Interventions/diagnostic procedures
During this period, the trainee should perform arterial and venous access according to the Seldinger technique.

Furthermore, the trainee should be trained to situate diagnostic catheters in the different chambers of the heart. The trainee should become familiar with the EP equipment and the different monitoring systems used during these procedures.

Device implantations
The trainee should perform regular PM implants and assist during the implantation of ICD/CRT devices.

Emergency department and in-hospital emergency
During this period, the trainee should participate in the management of patients with urgent HR disorders under close supervision.

Months 5–8
Outpatient clinic
During this period, the trainee will treat patients at the outpatient clinic under close supervision of one of the trainers. In addition, the trainee should be trained in non-invasive EP (like Holter monitoring, ECG recording, and neuro-humoral testing).

Device follow-up
During this period, the trainee will learn to perform the technical follow-up of device patients.

In addition, the trainee must become familiar with the different devices in the HR department. The trainee should be able to perform routine technical follow-ups independently. The trainee should learn to troubleshoot device-related problems under close supervision.

Arrhythmia clinic
During this period, the trainee will be responsible for the arrhythmia clinic under the supervision of one of the trainers.

Interventions/diagnostic procedures
During this period, the trainee must be able to perform simple diagnostic procedures.

Device implantations
During this period, the trainee should perform regular PM implants and assist during implantation of ICDs and CRT devices.

Emergency department and in-hospital emergency
During this period, the trainee may participate in the emergency department/in-hospital emergency duty service under supervision.

Months 9–12
Outpatient clinic
During this period, the trainee will treat patients at the outpatient clinic independently, but should discuss all patients with one of the supervisors. Furthermore, the trainee should be able to analyse Holter recordings and ECGs independently.

Device follow-up
During this period, the trainee should perform the technical follow-up of device patients.

In addition, the trainee should be able to trouble shoot device-related problems.

Arrhythmia clinic
During this period, the trainee will be responsible for the arrhythmia clinic under supervision of one of the trainers.

Interventions/diagnostic procedures
During this period, the trainee should perform diagnostic procedures and assist during ablation procedures. Furthermore, the trainee should be able to perform a periocardiocentesis in case of an emergency after training.

Device implantations
During this period, the trainee should perform regular PM implants independently and act as operator during ICD implantations under supervision. He/she will assist during CRT implantation.

Emergency department and in-hospital emergency
During this period, the trainee will participate in the emergency department/in-hospital emergency duty service under close supervision.

Months 13–16
Outpatient clinic
During this period, the trainee will treat patients at the outpatient clinic independently and should be able to decide if patients should be referred for catheter ablation or device implantation.

Device follow-up
During this period, the trainee will supervise the follow-up programme. Furthermore, the trainee should be able to solve most device-related problems independently.

Arrhythmia clinic
During this period, the trainee will supervise the arrhythmia clinic (under the supervision of the programme director).

Interventions/diagnostic procedures
During this period, the trainee must perform ablation procedures as the first operator and assist during complex procedures, such as ventricular tachycardia ablation, atrial fibrillation ablation, and atypical atrial flutter ablation. Furthermore, the trainee should be able to perform most diagnostic procedures independently. The trainee should become familiar with transseptal punctures.

Device implantations
During this period, the trainee should perform regular PM and ICD implants and become the first operator in CRTs implantations.

Emergency department and in-hospital emergency
During this period, the trainee will participate in the emergency department/in-hospital emergency duty service under supervision of the programme director.

Months 17–20
During this period, the trainee should be trained to perform complex ablation procedures. Furthermore, the trainee should be able to perform transseptal punctures as the first operator.

Months 21–24
Outpatient clinic
During this period, the trainee must be able to supervise the outpatient clinic (under the supervision of the programme director).

Device follow-up
During this period, the trainee must be able to supervise the device outpatient clinic.

Arrhythmia clinic
During this period, the trainee will be responsible for the arrhythmia clinic.

Interventions/diagnostic procedures
During this period, the trainee should be able to perform all ablation procedures as first operator.

Device implantations
During this period, the trainee will perform regular PM implants and ICD and CRT-D/PM implantations.

Emergency department and in-hospital emergency
During this period, the trainee will participate independently in the emergency department/in-hospital emergency duty service.

Indicative number of procedures
The numbers of procedures performed have been used for a long time as a measure of training. While recognizing the crude nature of the number of procedures as an assessment method, the use of the indicative number of procedures is a useful means of ensuring sufficient exposure to a technique. This section details the minimum number of procedures recommended to be performed by the trainee during the training period. In addition, the levels of competence expected for a given area of a subject matter are provided with the same definitions used in the ESC Core Curriculum for the General Cardiologist,⁴ are complementary to them, and are defined as follows:

– Level I: experience of selecting the appropriate diagnostic modality and interpreting the results or choosing an appropriate treatment for which the patient should be referred. This level of competence does not include performing a technique.

– Level II: practical experience, but not as an independent operator, including assisting in or performing a particular technique or procedure under the guidance of a superior.

– Level III: is able to independently perform the technique or procedure unaided.

The trainee should review at least 1000 12-lead ECGs during the training period in addition to the >1000 that he or she should have had reviewed during the cardiology specialty training. In addition, the trainee should gain basic knowledge (level of competence I) in ECG-based techniques, including T-wave alternant analysis, body-surface potential mapping, and heart rate variability. The trainee should also be familiar (level of competence I) with surgery for HR disorders. The recommended procedural numbers and the levels of competence for the rest of the HR procedures are presented in Tables 13 and 14.

View this table: [in this window] [in a new window]   Table 13 Minimum recommended procedural numbers and levels of competence in non-invasive techniques to be achieved by the HR specialist during training

 

View this table: [in this window] [in a new window]   Table 14 Minimum recommended procedural numbers and levels of competence in invasive techniques to be achieved by the HR specialist during training

 

	Training centre and trainer requirements

Top Abstract Introduction Definitions and glossary Summarized syllabus General learning objectives Training requirements and plan Training centre and trainer... Training assessment Continuous medical education and... Author's funding by private... References

 
Training centre requirements
Formal training in HR management must be carried out in a centre that is recognized and accredited by an official organization, such as the EHRA, as a HR Subspecialty training centre. The training centre should be integrated within a full-service cardiology department, which includes an interventional unit, a cardiac imaging department, a heart-failure unit, and a cardio-surgical unit. The institution must be a training centre for general cardiologists and a recognized centre (by the health authorities or according to national laws) for performing all arrhythmia and device-related procedures with the only exception of arrhythmia surgery. Specific arrhythmia surgery programmes have decreased during the last two decades and nowadays few centres perform surgery for ventricular tachycardia or other forms of supraventricular tachycardia other than atrial fibrillation. Therefore, it is acceptable to admit a centre's training programme that collaborates with other centres performing arrhythmia surgery. The centre must have access to at least one dedicated and fully equipped EP catheterization laboratory, it must record procedural related data, and it and must have a complication registration system.

The training centre must employ at least two fully trained, advisable HR specialists, who should be recognized (accredited) by the EHRA. Both of them must be actively involved in the field of HR management for at least 70% of the time (based on a full-time employment). The programme supervisor should be a fully trained HR specialist recognized by the EHRA and who has at least 5 years of experience in the field. In addition, the training programme staff should be active in clinical research related to the field of HR management.

Clinical practice activities: procedures and numbers
The training centre should perform PM, ICD, and CRT device implantation and replacement, invasive electrophysiological procedures, and the following catheter ablation procedures on a regular basis:

– Accessory pathway mediated tachycardias

– AV nodal re-entrant tachycardia/junctional tachycardia

– Ectopic atrial tachycardia

– Atrial flutter from the right and the left atrium

– Atrial fibrillation

– AV conduction ablation

– Ventricular tachycardia: idiopathic and in patients with structural heart disease

The training centre should perform yearly at least 250 invasive electrophysiological diagnostic procedures, 200 catheter ablation procedures, 200 PM implantations/replacements, 50 ICDs implantations/replacements, and 20 CRTs implantations/replacements.

Educational activities
The training centre should organize regular theoretical educational activities on a weekly basis, such as meetings reviewing topics and discussing patients, indications, results, and procedural related complications. In addition, the training centre must encourage the trainee's attendance at official international subspecialty meetings.

Research activities
A training centre should maintain a minimum level of scientific activity and interest in heart rhythmology, which is endorsed by the presentation of at least three related scientific communications at an EHRA recognized official subspecialty congress (Europace, European Society of Cardiology congress, American Heart Association scientific sessions, American College of Cardiology scientific sessions, HR Society congress, and European national societies annual congresses) during the previous 3 years and the publication of at least one scientific article related to heart rhythmology in a journal with an objective ‘impact factor’ during the previous 3 years.

Infrastructure and equipment
The training centre should be equipped with the state-of-the-art equipment in order to offer current technology treatment approaches. The centre should have the following available on-site:

– Up-to-date monitoring equipment.

– Modern catheterization laboratories: as x-ray exposure is a serious issue in invasive EP and device implantation procedures, X-ray systems allowing dose-reduction and image optimization should be used. Furthermore, X-ray exposure should be As Low As Reasonably Achievable (ALARA principle). X-ray exposure (in mSv or Gy) should be recorded during each procedure. Personal protection should be available. Only trained personnel (according to national laws) should be allowed to operate X-ray equipment.

– Due to the risk of haemodynamic problems and the risk of ventricular arrhythmias, each catheterization laboratory should be equipped with resuscitation equipment and the possibility to sedate and monitor patients. Preferably, it should be possible to deliver deep anaesthesia.

– It should be possible to perform an emergency periocardiocentesis. Operators should have experience of this procedure.

– A multichannel recording system (at least a 16-channel recording system) and a multi-programmable stimulator should be available to perform diagnostic and catheter ablation procedures.

– 3D electro-anatomical mapping is a prerequisite to perform complex ablation procedures (such as ablation of atrial fibrillation or ventricular tachycardia) and it should be available.

– Equipment to evaluate PM and ICD leads during implantation should be available.

– The catheterization laboratory should fulfil criteria to allow implantation of devices. If devices are implanted in an operating theatre, X-ray equipment should meet the same standards as for the catheterization laboratory.

– Patient database: a patient database containing procedural data, complications, and outcome (up to 1 year follow-up) should be available and easily accessible. CRT/ICD centres should have a database containing all technical data about implanted devices and leads. Furthermore, this database should be used to follow device patients.

– MRI scanner: in order to screen and diagnose patients with complex arrhythmias, such as patients with arrhythmogenic right ventricular cardiomyopathy, an MRI scanner should be available.

– Multislice-CT scanner: it is advisable that centres have access to a multislice-CT scanner to allow evaluation of coronary pathology and to reconstruct 3D anatomy.

– Nuclear imaging techniques: nuclear imaging techniques should be used to evaluate patients with ventricular arrhythmias. Nuclear imaging may serve as a ‘gate keeper’ during the analysis of patients with ventricular arrhythmias.

– A fully integrated and structured heart failure treatment programme should be operational. At least one heart failure specialist should be involved in the decision-making process before the actual CRT implant is carried out. Preferably, the centre has a heart failure outpatient clinic.

Certifying as a training centre
Training centres should comply with the National Quality insurance programme. The National Working Group on Arrhythmias should endorse the training centre and trainers.

	Training assessment

Top Abstract Introduction Definitions and glossary Summarized syllabus General learning objectives Training requirements and plan Training centre and trainer... Training assessment Continuous medical education and... Author's funding by private... References

 
Assessment of the trainee and the training programmes is essential, both to guarantee a minimum level of knowledge and practical competence of the trainee and to promote continuous improvement of the training programmes. The assessment methods should include reports by the training programme supervisor and the national society HR organizations, a logbook of procedures, written examinations, and assessment of professionalism. In addition, the assessment process should include an appeal procedure, as an additional quality control of the system provided by their participants, and a revocation procedure for accredited professionals or centres that act incompetently or in an unsatisfactory manner. This assessment process should aim to develop a certification or accreditation system (see glossary) for HR specialists, not to delimit the legal capacity of professional training in this field of cardiology, but for objective certification of the qualification of training personnel and training centres, with the guarantee of required quality from a strictly professional and technical point of view. The implantation of such an accreditation system could play an important role as an informative element when taking decisions in the case of health authorities as well as service professionals and users. The availability of an independent and objective standard would facilitate the consensus of health professionals and the standardizing activities of the National Health Authorities, combined with the European Health Directives.

The EHRA has undertaken the task of assessment and accreditation of centres and professionals by verifying the candidates’ credentials, log books and merits, evaluating and verifying the centre and the candidates’ professional competence, and implementing and holding accreditation examinations. The centres and candidates who pass the assessment process successfully are entitled with a diploma/certificate indicating training excellence and proficiency, respectively, which will be endorsed and accredited by the EHRA (see Figures 1 and 2). The first EHRA's Accreditation exams for Invasive Electrophysiology and for Implantable devices were held in 2005 and the first EHRA's Accreditation titles were issued in 2006.⁵

View larger version (31K): [in this window] [in a new window] [Download PowerPoint slide]   Figure 1 Accreditation certification title issued by EHRA for professionals who are trained in implantable cardiac rhythm devices and who have passed a theoretical examination.

 

View larger version (26K): [in this window] [in a new window] [Download PowerPoint slide]   Figure 2 Accreditation certification title issued by the EHRA for professionals trained in implantable cardiac rhythm devices and who have passed a theoretical examination.

 
Trainee assessment
Reports
A written report signed and stamped by the Training Programme Director, as well as the Head of Service and/or Manager of the corresponding centre certifying that the applicant has completed full-time training of at least 2 years in the said laboratory. This report should detail the activities undertaken, and the degree of competence and autonomy attained by the trainee, and allow verification that all the modalities of HR investigation and management modalities have been performed. This report should not be limited to clinical techniques, but it should also include course attendance, teaching, and research activities. In addition, a letter from the national society HR organizations will support the existence and quality of the training centre and programme supervisor and the lack of knowledge about inappropriate or unethical conduct of the trainee or the training supervisor. A normalized form for these reports should be used for convenience.

Procedural logbooks
The trainees should provide a continuous record (logbook) report detailing their cardiac electrophysiological and HR implantable device training and experience, which must include the required clinical procedures as the first and secondary operator during the training. The log book should contain a summary with the number of procedures performed, the level of competence achieved, and a list of the main procedures with the following data:

1. Centre where the procedure was performed
   
2. Date of the procedure
   
3. Patient's birth date and sex
   
4. The patient's clinical history or register numbers (where the former is unavailable and if permitted by the national data protection law)
   
5. Diagnosis
   
6. Type of procedure (diagnostic study, ablation, PM, ICD, and CRT)
   
7. Result of the procedure (success or failure)
   
8. Type of complications, if applicable.
   

This log book will have an electronic format to facilitate data input and importation from other computer applications. A database will be available and will be used to ease the process of information and requirement submission (internet-based). A printed copy of the log book must be dated, signed, and stamped by the Head of Service and/or Manager of the corresponding centre. The candidates for accreditation by this method must attach a standard signed letter of authorization agreeing to facilitate and cooperate with an eventual audit of the procedures reported. The EHRA reserves the right to make formal complaints or accusations within a legal or professional ethics framework as considered necessary in the case of data falsification.

Theoretical examinations
Knowledge will also be assessed by a single theoretical examination on all aspects of HR management. This examination may be divided into two separate examinations, invasive cardiac EP and implantable devices, if it is considered convenient in terms of exam duration or candidate participation promotion due to particular national idiosyncrasies or other reasons. Minor aspects of the examinations may change from one edition to another, but they should essentially consist of a test with 100–200 multiple-choice questions, with five possibilities being offered of which only one will be correct. These questions will include both academic knowledge and the analysis of traces or practical clinical suppositions and decision-making. The question content is shown in the Syllabus. The number of questions with the purely clinical cardiac electrophysiological and implantable devices content will not be <60%. The average difficulty grade of the exam should be balanced (between 2.5 and 3.5 according to a defined scale shown in Table 15). The examinations will be compiled by an Accreditation Committee.

View this table: [in this window] [in a new window]   Table 15 Average difficulty scale for questions used in a HR subspecialty accreditation examination

 
The examination will use specially designed forms for the confidentiality and privacy of the participants, The Accreditation Committee will, at all times, maintain the integrity and confidentiality of the process and will be empowered to invalidate the examination of any candidate if irregularities are detected.

Assessment of professionalism
Assessment of whether the trainee qualifies as a professional or not is important in the evaluation process of the trainee. The 360° assessment is a holistic assessment.⁶ Professionals gravitating and with whom the trainee is interacting are prompted by email to answer questions on the trainee. These questions relate to attitude as well as professional aptitudes. Answers are then processed to reveal the trainee's areas of strength and areas for improvement. This method is largely implemented in commercial companies and it should be desirable to implement it in the future. Alternatively to 360° assessment, a simple questionnaire (on team work, etc.) of 10 questions could be completed by several co-workers (programme director, nurses, surgeons, other trainees, etc.).

Training centre assessment
The Accreditation Committee will announce the period for the submission of accreditation centre applications. Accreditation candidates, whether European or non-European, must submit a standard form, a report on the centre's activities detailing all the merits for patient care, research, and training, and a letter from the national society HR organizations supporting the quality of the training centre and the programme supervisor and the lack of knowledge about inappropriate or unethical conduct.

The Accreditation Committee may organize audits or delegate them to the National Working Groups on HR management, which would act as team of evaluators under the support and expertise of the Accreditation Committee. For this purpose, candidate centres for accreditation by this method must attach a standard signed letter of authorization agreeing to facilitate and cooperate with an eventual audit. The EHRA reserves the right to make formal complaints or accusations within a legal or professional ethics framework as considered necessary in the case of data falsification.

After evaluating the applications, checking the documentation, and performing the corresponding audits, the Accreditation Committee will notify candidates about the result of their application by letter.

Assessment appeals
A period for appeals will be opened after the candidates and the centres are notified of their accreditation application exam result and resolution. The candidate should address his/her appeal or complaint to the Chairperson of the Accreditation Committee.

Reaccreditation and revocation
At its discretion, the EHRA is empowered to revoke accreditation if the accredited professional or centre was not qualified to receive accreditation at the time it was granted. Similarly, accreditation may be revoked if it is proven that the accredited professional or centre acts incompetently or in a professionally or ethically unsatisfactory manner.

The EHRA reserves the right to institute proceedings through all legal and administrative means as deemed necessary in the case of inappropriate use, whether intentional or not, of the denomination ‘EHRA Accredited’ and its derivatives.

Accreditation committee
Composition
The committee will be composed of 5 to 10 EHRA members (it is advisable that they are accredited), 1 of these being the chairperson of the Committee and, therefore, necessarily a member of the EHRA Board. These members will be appointed by the EHRA Board of Directors. Given that no EHRA members will be accredited when the Accreditation System is initiated, the first Accreditation Committees will be formed by EHRA members with recognized prestige and merit.

Functions
The functions of the Accreditation Committee are as follows:

• Announce and open the period for the call for applications for Accreditation from both professionals and training centres, as well as the management of the same.
  
• Co-ordinate the degree and diploma verification and audits to evaluate the merits of those professionals and centres applying for accreditation, as well as participation in carrying out the same when deemed necessary.
  
• Prepare and compose the theoretical examination exercises; maintain a question database for the composition of future theoretical examinations.
  
• Co-ordinate and manage the theoretical accreditation examination results evaluation.
  
• Offer and attend any possible appeals from accreditation candidates about the evaluation of the merits they present or the results of their theoretical accreditation examination.
  
• Submit ratification of accreditation of those candidates who are considered suitable by virtue of the results obtained in the theoretical examination to the EHRA Board of Directors Committee.
  
• Maintain a register of those who are accredited together with their merits and requisites accomplished.
  
• Maintain a register of activities and the activities of previous Accreditation Committees.
  
• Promote and support the organization of training courses.
  
• Notify the EHRA Board of Directors of any changes in the accreditation system that are deemed necessary to adapt to changes and evolution in HR management.
  
• Implement any changes that are deemed necessary to adapt the accreditation system to changes and evolution in HR management.
  
• Co-ordinate this adaptation with those in other national or European accrediting entities, and if considered appropriate, those of non-European international standing.
  
• Take steps to publicize the accreditation system so it becomes known and can serve as a reference for third parties.
  
• Keep the EHRA Board of Directors informed about the activities of, the status of, and the changes in the accreditation system.
  

Frequency of meetings
The Accreditation Committee will hold ordinary meetings at least twice a year. The Secretary to the Committee may call extraordinary meetings at the request of the Chairman of the EHRA Board of Directors for matters of sufficient urgency or importance.

Attendance
Accreditation Committee meetings will always be held with a quorum equal to half the members plus one.

Dependence
The Accreditation Committee will be appointed by and organically dependent on the EHRA Board of Directors.

Elections
Designation for committee members will be held every 2 years, following the elections for the EHRA Board of Directors. With the objective of guaranteeing renewal and a degree of continuity, half of the members should be reelected every 2 years.

	Continuous medical education and maintaining competence

Top Abstract Introduction Definitions and glossary Summarized syllabus General learning objectives Training requirements and plan Training centre and trainer... Training assessment Continuous medical education and... Author's funding by private... References

 
Continuous medical education (CME) in cardiology subspecialities are important because knowledge and skills are continuously developing and evolving. Continuous learning and practice are required to maintain standards and practice and because substantial changes may occur in clinical practice or the health-care environment. Training seminars and international specialist conferences must be attended (at least two per year). Courses offered in innovative techniques employed in specialized laboratories should be also attended. Continued practice may indicate 16 h per week working in the subspecialty field. Continued learning may indicate 200 CME credits over a 5 year period in the field of HR management.

Therefore, accreditation as a HR specialist is time limited and will require individuals to go through a process of reaccreditation and recertification. The time period required for reaccreditation will be 10 years or, if considered advisable by the Accreditation Committee, whenever a suitable electronic platform is available. Reaccreditation requires submission and validation of evidence of continued learning and practice within the subspecialty.

	Author's funding by private biomedical companies*

Top Abstract Introduction Definitions and glossary Summarized syllabus General learning objectives Training requirements and plan Training centre and trainer... Training assessment Continuous medical education and... Author's funding by private... References

 

Author Consulting fees honoraria Speaker's Bureau Ownership partnership principal Research grants Fellowship support and other benefit Jose L. Merino Magnetecs, Medtronic, St Jude Medical, Sanofi-Aventis Meda Pharma, Medtronic, St Jude Medical, Sanofi-Aventis None Magnetecs Boston Scientific, Medtronic, St Jude Medical Fernando Arribas Sanofi-Aventis Boston Scientific, St Jude Medical None None None Giovanni Luca Botto None None None None None Heikki Hukuri None Biotronik, Medtronic None Medtronic None Lars I. Kraemer Medtronic, Sorin Group Biotronik, Boston Scientific, Medtronic, Sorin Group, St Jude Medical None None None Cecilia Linde Medtronic, St Jude Medical Medtronic, St Jude Medical None Medtronic None John M. Morgan None None None None None Martin Schalij Boston Scientific Biotronik, Boston Scientific None Biotronik, Boston Scientific, Medtronic, St Jude Medical None Emmanuel Simantirakis None None None None None Christian Wolpert None Bard, Biotronik, Boston Scientific, Medtronic, St Jude Medical None None None Marie-Christine Villard None None None None None Julie Poirey None None None None None Svya Karaim-Fanchon None None None None None Keren Deront None None None None None

*Funding received was not related to this study.

	Footnotes

 
This document was approved by the European Heart Association Board in March 2009.

Heart House staff

	References

Top Abstract Introduction Definitions and glossary Summarized syllabus General learning objectives Training requirements and plan Training centre and trainer... Training assessment Continuous medical education and... Author's funding by private... References

 
[1] Brugada J, Vardas P, Wolpert C. The EHRA white book 2008: the current status of Cardiac Electrophysiology in ESC member countries. http://www.escardio.org/communities/EHRA/publications/Documents/ehra-white-book-2008.pdf (10 May 2009, date last accessed).

[2] Lopez-Sendon J, Mills P, Weber H, Michels R, Di MC, Filippatos GS, et al. Recommendations on sub-speciality accreditation in cardiology: The Coordination Task Force on Sub-speciality Accreditation of the European Board for the Speciality of Cardiology. Eur Heart J (2007) 28:2163–71.[Free Full Text]

[3] American Board of Internal Medicine: Exam Administration History. http://www.abim.org/about/examInfo/year.aspx. (10 May 2009, date last accessed).

[4] Kearney P, Oktay Ergene A, Escaned J, Flachskmpf F, Griebenow R, Kristesen S, et al. Education Committee of the European Society of Cardiology. In: Core Curriculum for the General Cardiologist. (2006) Nice, France: European Society of Cardiology.

[5] EHRA Accredited professionals in Cardiac Pacing and Electrophysiology. http://www.escardio.org/communities/EHRA/accreditation/Pages/ accredited-professionals-cp-ep.aspx (10 May 2009, date last accessed).

[6] Whitehouse A, Walzman M, Wall D. Pilot study of 360° assessment of personal skills to inform record of in-training assessments for senior house officers. Hosp Med (2002) 63:172–5.[Web of Science][Medline]

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