American College of Cardiology/American Heart Association clinical competence statement on echocardiography: a report of the American College of Cardiology/American Heart Association/American College of Physicians--American Society of Internal Medicine Task Force on Clinical Competence.

Abstract

HomeCirculationVol. 107, No. 7American College of Cardiology/American Heart Association Clinical Competence Statement on Echocardiography Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBAmerican College of Cardiology/American Heart Association Clinical Competence Statement on EchocardiographyA Report of the American College of Cardiology/American Heart Association/American College of Physicians—American Society of Internal Medicine Task Force on Clinical Competence Writing Committee Members Miguel A. Quiñones, MD, FACC, Chair, Pamela S. Douglas, MD, FACC, FAHA, Elyse Foster, MD, FACC, FAHA, John GorcsanIII, MD, FACC, FAHA, Jannet F. Lewis, MD, FACC, FAHA, Alan S. Pearlman, MD, FACC, FAHA, Jack Rychik, MD, FACC, Ernesto E. Salcedo, MD, FACC, James B. Seward, MD, FACC, J. Geoffrey Stevenson, MD, FACC, Daniel M. Thys, MD, FACC, FAHA, Howard H. Weitz, MD, FACC, William A. Zoghbi, MD, FACC, FAHA, Mark A. Creager, Task Force Members:, MD, FACC, Chair, William L. WintersJr, MD, MACC, FAHA, Michael Elnicki, MD, FACC, FACP, John W. HirshfeldJr, MD, FACC, FAHA, Beverly H. Lorell, MD, FACC, FAHA, George P. Rodgers, MD, FACC, Cynthia M. Tracy, MD, FACC, FAHA and Howard H. Weitz, MD, FACC, FACP Writing Committee Members Search for more papers by this author , Miguel A. QuiñonesMiguel A. Quiñones Search for more papers by this author , Pamela S. DouglasPamela S. Douglas Search for more papers by this author , Elyse FosterElyse Foster Search for more papers by this author , John GorcsanIIIJohn GorcsanIII Search for more papers by this author , Jannet F. LewisJannet F. Lewis Search for more papers by this author , Alan S. PearlmanAlan S. Pearlman Search for more papers by this author , Jack RychikJack Rychik Search for more papers by this author , Ernesto E. SalcedoErnesto E. Salcedo Search for more papers by this author , James B. SewardJames B. Seward Search for more papers by this author , J. Geoffrey StevensonJ. Geoffrey Stevenson Search for more papers by this author , Daniel M. ThysDaniel M. Thys Search for more papers by this author , Howard H. WeitzHoward H. Weitz Search for more papers by this author , William A. ZoghbiWilliam A. Zoghbi Search for more papers by this author , Mark A. CreagerMark A. Creager Search for more papers by this author , William L. WintersJrWilliam L. WintersJr Search for more papers by this author , Michael ElnickiMichael Elnicki Search for more papers by this author , John W. HirshfeldJrJohn W. HirshfeldJr Search for more papers by this author , Beverly H. LorellBeverly H. Lorell Search for more papers by this author , George P. RodgersGeorge P. Rodgers Search for more papers by this author , Cynthia M. TracyCynthia M. Tracy Search for more papers by this author and Howard H. WeitzHoward H. Weitz Search for more papers by this author Originally published25 Feb 2003https://doi.org/10.1161/01.CIR.0000061708.42540.47Circulation. 2003;107:1068–1089Table of ContentsPreamble 1069 A. Introduction 1069Purpose of this Clinical Competence Statement 1070Document Format 1070 B. General Principles 1070Basic Knowledge of Ultrasound Physics 1070Technical Aspects of the Examination 1071Anatomy and Physiology 1071Recognition of Simple and Complex Pathology 1071 C. Transthoracic Echocardiography in Adult Patients 1071Overview and Indications for the Procedure 1071Minimum Knowledge Required for Performanceand Interpretation 1072Training Requirements 1072Proof of Competence 1073Board Examination 1074Certification 1074Maintenance of Competence 1074D. Transeophageal Echocardiography 1074Overview and Indications for the Procedure 1074Minimum Knowledge Required for Performanceand Interpretation 1074Training Requirements 1075Proof of Competence 1076Maintenance of Competence 1076E. Perioperative Echocardiography 1077Overview and Indications for the Procedure 1077Minimum Knowledge Required for Performance and Interpretation 1077Training Requirements 1078Proof of Competence 1079Maintenance of Competence 1079F. Stress Echocardiography 1079Overview and Indications for Procedure 1079Minimum Knowledge Requirements for 1080Performance and InterpretationTraining Requirements 1081Proof of Competence 1081Maintenance of Competence 1081G. Echocardiography for CHD Patients 1081Overview and Indications for Procedure 1081Minimum Knowledge Required for Performance and Interpretation 1082Technical Aspects of the Examination 1082Anatomy and Physiology 1082Recognition of Simple and Complex Pathology 1082Training Requirements 1083Proof of Competence 1083Maintenance of Competence 1083H. Fetal Echocardiography 1083Overview and Indications for Procedure 1083Minimum Knowledge Required for Performanceand Interpretation 1084Training Requirements 1085Proof of Competence 1085Maintenance of Competence 1086I. Emerging New Technologies 10861. Hand-Carried Ultrasound Devices 1086 Overview and Indications for the Procedure 1086Minimum Knowledge Required for Performanceand Interpretation 1086 Training Requirements 1086 Proof of Competence 1086 Maintenance of Competence 10872. Contrast Echocardiography 1087 Overview and Indications for the Procedure 1087 Minimum Knowledge Required for Performance and Interpretation 1087 Training Requirements 1087 Proof and Maintenance of Competence 10873. Intracoronary and Intracardiac Ultrasound 1087 Overview and Indications for the Procedure 1087 Minimum Knowledge Required for Performance and Interpretation 1087 Training and Competence Requirements 10884. Echo-Directed Pericardiocentesis 1088 Overview and Indications for the Procedure 1088 Minimum Knowledge Required for Performance 1088and Interpretation Training Requirements 1088 Maintenance of Competence 1088 References 1088PreambleThe granting of clinical staff privileges to physicians is a primary mechanism used by institutions to uphold the quality of care. The Joint Commission on Accreditation of Health Care Organizations requires that the granting of continuing medical staff privileges be based on assessments of applicants against professional criteria specified in the medical staff bylaws. Physicians themselves are thus charged with identifying the criteria that constitute professional competence and with evaluating their peers accordingly. Yet, the process of evaluating physicians’ knowledge and competence is often constrained by the evaluator’s own knowledge and ability to elicit the appropriate information, problems compounded by the growing number of highly specialized procedures for which privileges are requested.The American College of Cardiology/American Heart Association/American College of Physicians—American Society of Internal Medicine (ACC/AHA/ACP–ASIM) Task Force on Clinical Competence was formed in 1998 to develop recommendations for attaining and maintaining the cognitive and technical skills necessary for the competent performance of a specific cardiovascular service, procedure, or technology. These documents are evidence-based, and when evidence is not available, expert opinion is utilized to formulate recommendations. Indications and contraindications for specific services or procedures are not included in the scope of these documents. Recommendations are intended to assist those who must judge the competence of cardiovascular health care providers entering practice for the first time and/or those who are in practice and undergo periodic review of their practice expertise. The assessment of competence is complex and multidimensional; therefore, isolated recommendations contained herein may not necessarily be sufficient or appropriate for the judging of overall competence.The ACC/AHA/ACP–ASIM Task Force makes every effort to avoid any actual or potential conflicts of interest that might arise as a result of an outside relationship or personal interest of a member of the ACC/AHA Writing Committee. Specifically, all members of the Writing Committee are asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest. These changes are reviewed by the Writing Committee and updated as changes occur.Mark A. Creager, MD, FACC, ChairACC/AHA/ACP–ASIM Task Force on Clinical CompetenceA. IntroductionThis document is a revision of the 1990 ACP/ACC/AHA Clinical Competence in Adult Echocardiography.1 The writing committee consisted of recognized experts in echocardiography representing the ACC, AHA, ACP–ASIM, American Society of Echocardiography (ASE), Society of Pediatric Echocardiography (SOPE), and the Society of Cardiovascular Anesthesiologists (SCA). The document has been approved for publication by the governing bodies of the ACC and the AHA, and endorsed by the ASE, SCA, and SOPE.Purpose of this Clinical Competence StatementPrevious publications have focused on training requirements for clinical competence in echocardiography. The first recommendations were made in 1986 by Bethesda Conference 17: Adult Cardiology Training2 and in 1987 by an expert panel of the ASE.3 They were followed by a previous version of the ACP/ACC/AHA physician clinical competence statement in 1990. These earlier recommendations were limited primarily to the practice of transthoracic echocardiography (TTE) in the adult patient. However, over the past 15 years echocardiography has evolved into a family of techniques (Table 1), each one with unique applications and its own set of cognitive skills and training requirements. Although the majority of these newer technologies were in their early phase of development in 1990, today they are used routinely in community hospitals all across the nation. In addition, the application of echocardiography in children and adults with congenital heart disease (CHD) has evolved into a highly specialized modality with its own set of cognitive skills and training requirements. Subspecialty societies such as the ASE have published recommendations for training and, in some cases, for competence in some of these newer techniques. In addition, guidelines for training in adult cardiovascular medicine in the form of a suggested core curriculum (COCATS) have included recommendations on training in echocardiography, first in 1995 and currently in a revised version.4 The recently formed National Board of Echocardiography (NBE) has also introduced guidelines for certification of special competence in adult echocardiography, which includes passing an examination in addition to specific training requirements. Separate certifications are granted for transesophageal echocardiography (TEE) and stress echocardiography. Recognizing the growths in technology and the increased complexity of echocardiography, the members of the ACC/AHA/ACP–ASIM Task Force on Clinical Competence commissioned this writing group to provide a new set of recommendations that recognize the different cognitive skills required for each of the new modalities and that address training, documentation and maintenance of competence. TABLE 1. Echocardiographic Modalities• Transthoracic two-dimensional/Doppler echocardiography• Transesophageal echocardiography• Intra-operative echocardiography• Stress echocardiography• Miniaturized hand-carried ultrasound• Contrast echocardiography• Intracardiac and intravascular ultrasoundDocument FormatThis document addresses competence in the performance and interpretation all the different modalities of echocardiography, including new applications of echocardiography in the operating room and the application of echocardiography in patients with complex CHD. The document also addresses the application of echocardiography using miniaturized hand-carried ultrasound instruments. For each of the applications, there will be a brief general overview, a discussion of the cognitive skills required and recommendations on training requirements, proof of competence, and maintenance of competence. Whenever possible, these recommendations will be linked to previously published recommendations made by specialty societies. In some situations, however, the writing group provides a set of recommendation that represent the consensus of this body of experts.This document makes an important distinction between training requirements and documentation of competence. Training requirements represent the minimal training experience that is considered necessary to achieve the skills for performance at a particular level. It is recognized that training is highly individualized and some trainees may require higher volume and more hours of exposure to a particular technique. Proof of competence, on the other hand, consists of a set of requirements that provide some assurance that physicians have gained the expertise needed to perform according to recognized standards.The sections on training requirements refer primarily to the training needed to achieve specific levels of expertise. Such training is expected to occur under the direct supervision of a qualified Level 3 or equivalent physician/teacher and for the most part, occurs during formal fellowship training in either cardiovascular medicine or cardiovascular anesthesiology. However, the document recognizes the fact that physicians trained prior to the development of these techniques may have properly learned their use while in practice. Thus, whenever possible, the document addresses training requirements and proof of competence for this group of physicians. Maintenance of competence requires the performance of a certain minimal volume of procedures and participation in continuing medical education (CME). This document recommends that physicians practicing echocardiography obtain a minimum of 5 hours per year of CME credits in echocardiography, as recommended recently by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL Newsletter 2001 Vol 4; Issue 2; page 5).B. General PrinciplesRegardless of the echocardiographic modality utilized, there is a body of knowledge required by any physician involved in performance and/or interpretation of echocardiograms that includes: ultrasound physics and use of instrumentation, anatomy, physiology, and pathology of the heart and great vessels (Table 2). TABLE 2. Basic Cognitive Skills Required for Competence in EchocardiographyCHD=congenital heart disease.• Knowledge of physical principles of echocardiographic image formation and blood flow velocity measurements.• Knowledge of instrument settings required to obtain an optimal image.• Knowledge of normal cardiac anatomy.• Knowledge of pathologic changes in cardiac anatomy due to acquired and CHD.• Knowledge of fluid dynamics of normal blood flow.• Knowledge of pathological changes in blood flow due to acquired heart disease and CHD.Basic Knowledge of Ultrasound PhysicsEchocardiographic imaging and Doppler systems generate ultrasound signals that follow the laws of physics. Appropriate utilization of these instruments and interpretation of the data generated require an understanding of the fundamental principles of ultrasound physics and how they relate to the images produced and the spectral and color Doppler information. This understanding is considered to be an important requirement for clinical competence in all modalities of echocardiography.Technical Aspects of the ExaminationAn essential component of the diagnostic accuracy of echocardiography is the skill and experience of the individual responsible for image and data acquisition. Technical skills related to echocardiographic data acquisition may be divided into two important skill sets: transducer manipulation and ultrasound system adjustments. Perhaps the most difficult and underestimated skill set to master is transducer manipulation, which is critical to obtaining optimal image quality in standard tomographic imaging planes, and optimal Doppler flow velocity signals. This is true regardless of the type of transducer utilized (i.e., transthoracic, transesophageal, or intravascular). The second set of technical skills includes appropriate knowledge of ultrasound instrument settings such as transducer frequency, use of harmonics, mechanical index, depth, gain, time-gain-compensation, dynamic range, filtering, velocity scale manipulations, and display of received signals.Anatomy and PhysiologyEchocardiography is a powerful diagnostic tool that provides immediate access for the evaluation of cardiac and vascular structures and assessment of heart function. Intrinsic to a competent echocardiographic examination is a thorough understanding of the anatomy and physiology of the heart and great vessels. Two-dimensional imaging can accurately quantify cardiac chamber sizes, wall thickness, ventricular function, valvular anatomy, and great vessel size. Pulsed, continuous-wave, and color-flow Doppler echocardiography, especially when combined with two-dimensional imaging, can be used to quantify blood flow velocities and calculate blood flow; assess intracardiac pressures and hemodynamics; and detect and quantify stenosis, regurgitation, and other abnormal flow states. Documentation of normal and abnormal cardiac anatomy and physiology must be accomplished by the individual performing the examination.Recognition of Simple and Complex PathologyThe ability to recognize both simple and complex pathology of the heart and great vessels is required for competence in echocardiography. A fundamental knowledge of cardiac pathology is required during data acquisition to tailor the examination appropriately and maximize demonstration of the abnormalities present. This includes the ability to modify standard imaging planes and optimize the Doppler beam angle of incidence to achieve this goal. In addition, an extensive knowledge of pathology and pathophysiology is required to interpret recorded echocardiographic data.C. Transthoracic Echocardiography in Adult PatientsOverview and Indications for the ProcedureTransthoracic two-dimensional and Doppler echocardiography is one of the most important and frequently performed diagnostic procedures for patients with cardiovascular disease. It provides highly accurate diagnostic information regarding the anatomy and physiology of the cardiac chambers, valves, major vessels, and pericardium in a noninvasive and instantaneous manner. This information can immediately affect the further diagnostic work-up for the patient, dictate therapeutic decisions, determine response to therapy, and predict patient outcome. Because transthoracic two-dimensional/Doppler echocardiography plays such a major role in the care of patients with suspected or known cardiovascular diseases, the widely accepted indications for the procedure span the breadth of cardiovascular medicine, including but not limited to the diagnosis of and guiding treatment for: coronary artery disease, valvular heart disease, heart failure, hypertensive heart disease, congenital abnormalities, complications of pulmonary disease, tumors/masses, cardiac trauma, pericardial disease, and others. Details of accepted indications have been recently revised (ACC/AHA Guidelines revision, publication pending). This section will discuss the cognitive requirements, training, proof of competence, and maintenance of competence for performance and/or interpretation of TTE in adult patients with acquired diseases and/or simple congenital heart defects. A separate section is dedicated to the use of echocardiography in pediatric patients and adults with complex congenital defects, as defined by the Task Force 1 Report from the 32nd Bethesda Conference on “Care of the Adult with Congenital Heart Disease.”5 Simple lesions are listed in Table 3. TABLE 3. Classification of Simple Congenital Lesions1. Valvular/Vascular Isolated congenital aortic valve disease Isolated sub-aortic membrane Isolated congenital mitral valve disease (except parachute valve, cleft valve) Isolated valvular pulmonic stenosis Uncomplicated Ebstein’s anomaly Simple coarctation of the aorta Sinus of valsalva aneurysm Persistent left superior vena cava2. Shunts Isolated atrial septal defects or patent foramen ovale Isolated small ventricular septal defects Isolated patent ductus arteriosusMinimum Knowledge Required for Performance and Interpretation (Table 4)TABLE 4. Cognitive Skills Required for Competence in Adult Transthoracic Echocardiography• Basic knowledge outlined in Table 2.• Knowledge of appropriate indications for echocardiography.• Knowledge of the differential diagnostic problem in each case and the echocardiographic techniques required to investigate these possibilities.• Knowledge of appropriate transducer manipulation.• Knowledge of cardiac auscultation and electrocardiography for correlation with results of the echocardiogram.• Ability to distinguish an adequate from an inadequate echocardiographic examination.• Knowledge of appropriate semi-quantitative and quantitative measurement techniques and ability to distinguish adequate from inadequate quantitation.• Ability to communicate results of the examination to the patient, medical record, and other physicians.• Knowledge of alternatives to echocardiography.Competence in performing and/or interpreting TTE in adult patients requires all of the basic knowledge of ultrasound physics, of instrumentation, and of cardiac anatomy, physiology and pathology described in the section on General Principles. Transducer manipulation is perhaps the most difficult and underestimated skill set to master when performing a transthoracic echocardiographic examination. It is the most important factor in obtaining optimal image quality in standard tomographic imaging planes and optimal Doppler flow velocity signals. As previously mentioned, appropriate knowledge of ultrasound instrument settings such as depth, gain, time-gain-compensation, dynamic range, filtering and display of received signals is essential for performing an optimal examination. Even though the majority of echocardiographic examinations are performed by sonographers and interpreted by physicians in most clinical settings in the United States, all physicians interpreting scans are required to be skilled in echocardiographic data acquisition as well. This facilitates the physician’s understanding of optimal echocardiographic data acquisition and technical quality. Physicians who are ultimately responsible for the diagnostic data should play an appropriate role in quality control and teaching in the sonographer-physician relationship. The echocardiographic physician should accordingly be available for consultation with the sonographer. Furthermore, a physician properly trained in echocardiographic data acquisition should be able to perform emergency bedside echocardiographic examinations when a sonographer is not available.Training Requirements (Table 5)TABLE 5. Training Requirements for Performance and Interpretation of Adult Transthoracic EchocardiographyCumulative Duration of TrainingMinimum Total Number of Examinations PerformedMinimum Number of Examinations InterpretedLevel 13 months75150Level 26 months150 (75 additional)300 (150 additional)Level 312 months300 (150 additional)750 (450 additional)Training in adult TTE remains intimately linked to training in other aspects of adult cardiovascular medicine, including cardiovascular catheterization, inpatient and outpatient clinical care, electrocardiography, pacing and electrophysiology, cardiac surgery, and other noninvasive imaging. The number of procedures required to accomplish clinical competence in two-dimensional Doppler echocardiography is, in reality, somewhat arbitrary because there is individual variation in cognitive, analytical, and manual-dexterity skills. Furthermore, the breadth of the clinical experience is equally as important as the numbers themselves, in that supplemental training may be required in centers where patient populations are skewed by specific referral patterns. It is important to emphasize that the numbers of examinations refer to comprehensive two-dimensional and Doppler echocardiographic studies that are diagnostic, complete, and quantitatively accurate.The numbers set forth in this document reflect the minimum requirements for the average trainee engaged in a training program in adult cardiovascular medicine. These numbers have been revised specifically to reflect the reality of mainstream training programs in cardiovascular medicine in the current era. A new distinction has been made between the performance of echocardiograms and interpretation of echocardiograms. Expert consensus remains that all physicians involved in the practice of the subspecialty of cardiovascular medicine or who participate in interpreting echocardiograms must be trained at a minimum level in performing echocardiograms (Table 5).Level 1 Training (3 months, 75 examinations performed, 150 examinations interpreted). Level 1 is defined as the minimal introductory training that must be achieved by all trainees in adult cardiovascular medicine. This includes a basic understanding of the physics of ultrasound, the fundamental technical aspects of the examination, cardiovascular anatomy and physiology as it relates to echo and Doppler imaging, and recognition of simple as well as complex cardiac pathology and pathophysiology. Level 1 trainees are required to train in echocardiography for a minimum of three months and perform and interpret a minimum of 75 two-dimensional and Doppler TTEs, and interpret an additional 75 two-dimensional and Doppler TTEs (total of 150 exams interpreted). This nominal hands-on training should enable a physician to expand on or clarify the data acquired by a sonographer, and to understand potential technical limitations and artifacts. Level 1 training is not sufficient for a trainee to perform or interpret echocardiograms independently.Level 2 Training (6 months, 150 examinations performed [75 additional] and 300 interpreted [150 additional]). Level 2 training is the minimum recommended training for a physician to perform and interpret echocardiograms independently. These requirements are specifically for transthoracic two-dimensional and Doppler echocardiography. Level 2 is defined as a minimum of an additional 3 months of training in echocardiography (6 months cumulative) and the addition of 150 transthoracic two-dimensional and Doppler examinations interpreted (300 cumulative exams interpreted). Additional training in special procedures, such as TEE and stress echocardiography, is detailed subsequently in this document. Although some experience in special procedures may be attained as a part of Level 2 training, in most instances, full competence in these areas will require additional training beyond Level 2.Level 3 Training (12 months, 300 transthoracic two-dimensional and Doppler echocardiograms performed [150 additional] and 750 interpreted [450 additional]). Level 3 represents a high level of expertise that would enable an individual to serve as a director of an echocardiography laboratory and be directly responsible for quality control and for the training of sonographers and physicians in echocardiography. Although these guidelines reflect the minimum number of TTE and Doppler studies, most physicians who are Level 3-trained will also have additional training in TEE and stress echocardiography. It should be emphasized that these numbers reflect the minimum examinations considered for clinical competence; many training programs will offer a greater experience in interpretation of transthoracic echocardiograms over the time periods previously outlined.Physicians who trained in Cardiovascular Disease before July 1990 (when the Level 1 to 3 guidelines were adopted) are considered clinically competent for independent performance and interpretation if they have either the equivalent of Level 2 training, as previously set forth, or have the experience of providing echocardiographic services for a minimum of 400 examinations performed and/or interpreted per year for a minimum of 3 years. Physicians who completed training in Cardiovascular Disease between July 1990 and July 1998 are considered clinically competent in echocardiography with the equivalent of Level 2 training, as previously set forth, if they completed 3 months training in echocardiography with performance and interpretation of 150 transthoracic echocardiograms, and have provided echocardiographic services of a minimum of 400 echo and Doppler examinations per year for a minimum of 2 years. Physicians who completed training in Cardiovascular Disease after July 1998 can be considered clinically competent in echocardiography with 6 months of training, a minimum of 150 examinations performed and a total of 300 examinations interpreted.Proof of Competence (Table 6)TABLE 6. Documentation and Maintenance of Competence in Transthoracic EchocardiographyTraining GuidelinesProof of CompetenceAll numbers represent minimum requirements.*Training program director, echocardiography laboratory director, or equivalent.†Periodic performance of echocardiographic studies is highly recommended.ICAEL=Intersocietal Commission for the Accreditation of Echocardiography Laboratories; NBE=National Board of Echocardiography.Documentation of Competence Training completed after July 1, 19981) Level 2 training1) Letter or certificate from training supervisor,*or2) NBE certification Training completed between July 1, 1990, and July 1, 19981) Level 2 training or1) Letter or certificate from training supervisor*or2) 3 months training, 150 studies performed and interpreted, and