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Europace (2009) 11, iii1–26 CORE CURRICULUM

doi:10.1093/europace/eup215

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), and Keren Deront‡ (France)
on behalf of the 2005 –2007 Accreditation Committee of the European Heart
Rhythm Association

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

Received 11 May 2009; accepted after revision 14 July 2009

Heart rhythm (HR) management is rapidly developing as a subspecialty within cardiology and it is imperative to promote and ensure suffi-
cient 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 fol-
lowing: definition of the scope of the HR speciality (Syllabus), development of minimum standards and objectives for training in HR manage-
ment (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 organ-
izations, 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 stan-
dards and practice because substantial changes may occur in clinical practice or the health-care environment.
-----------------------------------------------------------------------------------------------------------------------------------------------------------
Keywords Accreditation † Arrhythmia † Curriculum † Education † Electrophysiology † Heart rhythm

Table of Contents
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii1
Introduction
DEFINITIONS AND GLOSSARY . . . . . . . . . . . . . . . . . . . . . iii2 Heart rhythm (HR) management is rapidly developing as a subspe-
SUMMARIZED SYLLABUS . . . . . . . . . . . . . . . . . . . . . . . . . . iii3 cialty within cardiology that is devoted to the diagnosis and the
GENERAL LEARNING OBJECTIVES . . . . . . . . . . . . . . . . . . iii7 treatment of cardiac rhythm disorders, including invasive evalu-
TRAINING REQUIREMENTS AND PLAN . . . . . . . . . . . . . . iii7 ation of their mechanisms, controlled destruction of arrhythmo-
TRAINING CENTRE AND TRAINER genic myocardium by percutaneous catheters, and implantation
REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii21 of cardiac rhythm management devices. Catheter ablation is the
TRAINING ASSESSMENT . . . . . . . . . . . . . . . . . . . . . . . . . iii22 therapy of choice for most supraventricular tachycardias. More
CONTINUOUS MEDICAL EDUCATION AND than 50 000 interventions are performed every year in Europe.1
MAINTAINING COMPETENCE . . . . . . . . . . . . . . . . . . . . . iii25 Device implantation for arrhythmia treatment, sudden death

†
This document was approved by the European Heart Association Board in March 2009.
* Corresponding author. Arrhythmia Research Unit, Hospital Universitario La Paz, P. Castellana 261, 28046 Madrid, Spain. Tel: þ34 619 97 4115, Fax: þ34 917277564,
Email: [email protected]
‡
Heart House staff
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2009. For permissions please email: [email protected].
iii2 J.L. Merino et al.

prevention, and cardiac resynchronization are practiced regularly The ESC, the EBSC, and the EHRA
nowadays, and are performed in more than 200 000 patients in The European Society of Cardiology (ESC) is a private, non-profit
Europe per year.1 The increase in the indications and the making organization. The goals of the ESC ‘to foster the develop-
number of all of these procedures depicts the present scenario ment of cardiology, to further scientific exchanges, to encourage
by emerging indications, an increasing number of invasive pro- personal contacts, and to establish standards of training for cardi-
cedures, and the establishment of new practising units and pro- ologists and those who work in the field of cardiovascular disease’
fessionals. Nevertheless, these procedures require cardiologists are clearly defined in the original statutes. The ESC, after 50 years
with comprehensive knowledge of HR disorders and who are of existence, has now broadened its goals and is ‘dedicated to
trained in cardiovascular catheter manipulation, heart electrical improving the quality of life of the European population by redu-
signal recording and interpretation, and device implantation and cing the impact of cardiovascular disease’. The society is comprised
follow-up to ensure both patient’s safety and quality. Thus, it of both European and foreign cardiologists and other professionals
appears to be imperative to promote and ensure sufficient and related to cardiovascular diseases. The Chairman and the Board of
homogeneous training and qualification in HR management Directors are selected biennially. The ESC does not receive public
amongst these professionals in Europe. funds and is neither legislative nor authoritative.
In addition, the European Council of Ministers adopted a rec- The Heart Rhythm Association (EHRA) is a registered branch of
ommendation on the development and implementation of systems the ESC, which specifically deals with aspects related to cardiac elec-
on 30 September 1997 to improve the quality and homogeneity of

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trical physiology and HR problems. Its general aim is to foster the
Health Care Services. The recommendation stated that quality development of specific areas of expertise in HR and to improve col-
systems must be publicly controlled through objective external evaluation laboration between the common interests of different Working
by independent organizations. Although training and accreditation Groups in certain areas. The goals of the EHRA ‘to improve the
programmes are conducted both nationally and regionally, coordi- quality of life of the European population by reducing the impact
nation at the European level is needed for two reasons in particular: of cardiac arrhythmias and reduce sudden cardiac death’ are
1. Transnational cooperation is not well organized resulting in the defined in the statutes. The EHRA maintains the links and cohesion
duplication of work and an inability to compare work with the entire ESC group, while allowing a more specific and a
implemented in different countries due to unnecessary meth- more fruitful development of its particular area of expertise.
odological variations. The EHRA is integrated in the EBSC (European Board for the
2. The development of a uniform and a consistent set of standards Specialty of Cardiology) Taskforce on Subspecialty Accreditation.
will provide a good tool to facilitate qualified health services and The EBSC is a composite of the ESC and the UEMS (Union of
ensure free movement across barriers, both for professionals the European Medical Specialists), which is linked to the European
and for patients. Commission. The mission of this task force is defining and promot-
ing standards, requirements, and procedures in subspecialty accred-
These two reasons are even more relevant nowadays due to the itation in cardiology. At present, the following subspecialties under
development experienced by the European health care systems, evaluation for recognition by this task force are acute cardiac
the increasing national integration of the European Union, and care, echocardiography, HR management, interventional cardiology,
the challenges currently arising, such as increased management nuclear cardiology, and cardiovascular magnetic resonance.2
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
Definitions and glossary
Rhythm Association (EHRA), in organizing such a European
Accreditation
system together with the Registries of European certified units,
Accreditation is a process resulting in a diploma/certificate indicat-
professionals, and activities. A European programme in this field
ing proficiency. This applies to individuals, institutions, and labora-
will be of utmost interest and will represent a harmonized and
tories. Different terms have been often used and confused with
uniform way to ensure high standards of excellence. Thus, the
accreditation including:
general aim is to organize a European Core Curriculum for the
HR specialist associated with an Accreditation System to certify – Accreditation: signifies granting credit or recognition, or proving
professional practice through the following objectives: certitude. It is voluntary and motivational, and its objective is
the improvement of quality. The standards measured are
1. Definition of the scope of the HR speciality (Syllabus)
optimal. It is performed in health centres, which already have
2. Development of a minimum standards and objectives rec-
the appropriate authorization from the corresponding official
ommendation for training in HR management (Core
organization to carry out a certain activity and, therefore, are
Curriculum)
already operational.
3. Development of an Accreditation model for European HR pro-
– Authorization: signifies granting permission. It is obligatory and it is
fessionals and teaching units (Accreditation)
always performed prior to opening a specific programme. Its
4. Development of a Registry for European HR accredited pro-
purpose is therefore legislative, that is to say, to verify compli-
fessionals and teaching units and its activity (Registries)
ance with the minimum standard criteria demanded before grant-
This document describes the EHRA system. ing authorization to commence a specific activity.
Core curriculum for the heart rhythm specialist iii3

– Inspection: signifies examining in detail or verifying. It is obligatory (CRT). Proficiency in this discipline requires also a basic knowledge
and it is implemented to maintain control. Its purpose is super- about invasive and non-invasive cardiac EP.
visory, that is to say, its objective is to check compliance with
the criteria demanded by the regulations once a programme is Organizations
opened. EBSC is the European Board for the Speciality of Cardiology.
– Homologation: signifies verifying authoritatively compliance with EBAC is the European Board for Accreditation in Cardiology.
determined specifications or properties. It can be voluntary or UEMS-CS is the Union Européenne des Médecins Spécialistes-
obligatory. The objective is to guarantee that the product com- Cardiology Section.
plies with previously defined specifications. The purpose is hom-
ologous. Minimum standards must be measured. It may or may
not be operational. Summarized syllabus
Heart rhythm management is a rapidly developing field with the
Certification
most extensive and complex knowledge base in cardiology. This
Certification is not used in this document. It is not equivalent to
has been recognized by some organizations, such as the American
accreditation; it involves passing an assessment of knowledge,
Board of Internal Medicine, which considers HR management to be
which is only a part of an accreditation process. Assessments of
sufficient in itself to constitute a subspecialty, a consideration that,
knowledge demonstrate objective competency in the theory

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until a short time ago, was not held by any other discipline in car-
within a field.
diology.3 In addition, the cardiologist, who is a subspecialist in this
area, must also understand other techniques and related areas,
Curriculum
many of which are necessary to undertake and interpret the pro-
A curriculum is a formal education plan for a training programme
cedures, and others without which their ability to take decisions
that intended to establish specific learning outcomes.
would be limited. The Subspecialty Syllabus is the comprehensive
index of the present knowledge in the HR Subspecialty, which
Syllabus
includes knowledge in both Invasive Cardiac EP and Cardiac
A syllabus is a listing of subject matters that are covered in a train-
Rhythm Implantable Devices. Development of such a comprehen-
ing programme.
sive knowledge base required by the HR specialist is warranted.
However, it must be recognized that such a syllabus should be con-
Logbook
sidered just as a summary because it is unrealistic to detail all the
A logbook is a record of the trainee’s practical experience.
possible aspects and variants related to the HR field reported in
the scientific literature. This is especially true since knowledge in
Heart rhythm specialist
this field is developing rapidly and both major and minor advances
A cardiologist with specific knowledge, training, skills, and attitudes
are regularly published in peer-reviewed scientific journals. There-
for the study, management, research, and teaching of the HR
fore, for formal aspects, the knowledge base of the HR subspeci-
disorders.
alty will consider all data and information related to it that has
been made public and are currently available as published work
Cardiac electrophysiology
in international peer-reviewed journals, either in the paper or
Cardiac electrophysiology (EP) is the field of cardiology related to
the electronic format. For a full list of peer-review journals,
the study and management of HR physiology and disorders. It
please refer to the major scientific citation indexes, such as
includes both invasive and non-invasive techniques. Invasive
Current Contents& or Medline&. Nevertheless, a summarized syl-
Cardiac EP is the discipline that involves the study, diagnosis, treat-
labus for the HR specialist, in general, and for Invasive Cardiac EP
ment, and prevention of cardiac arrhythmias through recording
and HR Implantable Devices, in particular, has a practical interest
electrical activity, stimulation, and the controlled creation of endo-
and is presented in this section.
cardic and epicardiac lesions in the heart and its principal vessels
through electro-catheters, which are generally introduced by the Syllabus for the heart rhythm specialist
percutaneous vascular route. Knowledge of the management of
1. Normal and abnormal anatomy of the heart and the conduction
HR implantable devices, as one of the diverse diagnostic and thera-
system
peutic approaches for HR disorder management, is also required
2. Normal and abnormal general physiology and heart EP, includ-
for proficiency in this specialty.
ing ion channels, cellular EP, autonomous system influences, and
the basic mechanisms of rhythm disorders, syncope, and sudden
Heart rhythm implantable devices:
death
pacemakers, defibrillators, and others 3. Arrhythmic disorders (epidemiology, genetics, pathophysiology,
Heart rhythm implantable devices are devices that are designed for clinical features and diagnosis, prognosis and risk evaluation,
implantation in the human body for the study, diagnosis, prevention, treatment, prevention, and ESC Guidelines):
or management of HR disorders. The most frequent HR implantable
3.1 Sinus node and atrial impulse formation and conduction
devices are pacemakers (PMs), implantable cardioverter–defibrilla-
disorders
tors (ICDs), and devices for cardiac resynchronization therapy
3.2 AV nodal and His-Purkinje conduction disorders
iii4 J.L. Merino et al.

3.3 Atrial and thoracic vein ectopy and tachycardias computed tomography (CT), nuclear imaging, angiograms,
3.4 Atrial flutter and other]
3.5 Atrial fibrillation 5.6 Autonomic nervous system evaluation:
3.6 Junctional and AV node ectopy and tachycardias 5.6.1 Carotid sinus massage
3.7 Accessory pathway mediated tachycardias 5.6.2 Supine to orthostatism for orthostatic hypotension
3.8 Ventricular ectopy and tachycardias evaluation
3.9 Ventricular fibrillation 5.6.3 Tilt testing
3.10 Autonomic disorders (carotid sinus hypersensitivity, 5.6.4 Other
neurocardiogenic syncope, and other) 5.7 Transoesophageal electrical evaluation
4. Arrhythmogenic diseases and syndromes (epidemiology, gen- 5.8 Invasive EP studies
etics, pathophysiology, clinical features and diagnosis, prognosis 5.9 Other
and risk evaluation, treatment, prevention, and ESC Guidelines): 6. Therapies in heart rhythmology and Clinical EP (rationale,
4.1 Ischaemic cardiomyopathy material and equipment, techniques and procedures, side-
4.2 Non-ischaemic cardiomyopathies: effects and complications, results, indications and contraindica-
4.2.1 Idiopathic dilated cardiomyopathies tions, and ESC Guidelines):
4.2.2 Hypertrophic cardiomyopathies 6.1 Physical and autonomous system manoeuvres

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4.2.3 Right ventricular arrhythmogenic cardiomyopathies 6.2 Resuscitation and life support
4.2.4 Neuromuscular cardiomyopathies 6.3 Drugs with antiarrhythmic effects
4.2.5 Valvular-related cardiomyopathies 6.4 Drugs for associated rhythm problems (anticoagulants,
4.2.6 Congenital diseases vasodilatators, and other)
4.2.7 Other (Chagas disease, etc.) 6.5 Transient electrical stimulation:
4.3 Channelopaties and other inherited syndromes: 6.5.1 Transcutaneous
4.3.1 Long and short QT syndromes 6.5.2 Transoesophageal
4.3.2 Brugada syndromes 6.5.3 Intracardiac percutaneous
4.3.3 Catecholaminergic polymorphic ventricular 6.6 Cardioversion and defibrillation
tachycardia 6.7 Invasive EP guided therapies
4.3.4 Congenital conduction disorders 6.8 Percutaneous catheter ablation
4.3.5 Other 6.9 Implantable HR devices (PMs, ICDs, CRTs, and other)
4.4 Other situations leading to rhythm disorders 6.10 General knowledge of cardiac and antiarrhythmic surgery
5. Diagnostic procedures and techniques in Heart Rhythmology 6.11 Other
and Clinical EP (rationale, materials and equipment, techniques 7. Professional, legal, ethical, and socioeconomical aspects
and procedures, complications, result interpretation, indications
and contraindications, and ESC Guidelines):
Specific syllabus for invasive cardiac
5.1 Clinical evaluation (history and physical examination)
electrophysiology
5.2 Electrocardiography (ECG):
This syllabus includes the comprehensive knowledge of the areas
5.2.1 Conventional 12-lead ECG included in the summarized syllabus for the HR specialist, but
5.2.2 ECG monitoring (Holter, event monitoring, with specific knowledge in invasive cardiac EP, as follows:
implantable event, and loop monitoring)
5.2.3 Heart rate variability and baroreflex sensitivity
1. EP laboratory equipment (fluoroscopy, catheters, sheaths, EP
5.2.4 Signal-averaged ECG
signal recording systems, navigation systems, programmed
5.2.5 T-wave and micro-T-wave alternants
electrical stimulation systems, and other)
5.2.6 Body surface mapping
2. Catheter placement techniques including cardiac access
5.3 ECG-pharmacological tests:
(transvenous, pericardial, and other), guiding means (fluoro-
5.3.1 Type I drugs for His-Purkinje system challenge scopic or non-fluoroscopic, manual or remote navigation, and
5.3.2 Type I drugs for Brugada ECG unmasking other), and other
5.3.3 Adrenaline for congenital long QT syndrome 3. ECG and EP signals (bipolar/unipolar, filters, voltage/timing/
unmasking morphology, and other)
5.3.4 Adrenaline/atropine for sinus node dysfunction 4. Programmed electrical stimulation techniques (pulse width/
5.3.5 Adenosine/ATP for sinus node and AV node amplitude, unipolar/bipolar, continuous/extrastimulus stimu-
dysfunction lation, atrial/ventricular/other location stimulation, pacing
5.3.6 Other algorithms, and other) and pharmacological tests and
5.4 Exercise tests modulation
5.5 General knowledge in imaging techniques [fluoroscopy, 5. Angiography of cardiac chambers and vascular structures, such
echocardiography, magnetic resonance imaging (MRI), as the pulmonary veins
Core curriculum for the heart rhythm specialist iii5

6. Basic EP principles (intervals, refractoriness, conduction vel- Specific syllabus for heart rhythm
ocity, block/gap, and other) implantable devices
7. Basic arrhythmia mechanisms (macroreentry, microreentry,
This syllabus includes the basic knowledge of the areas included in
automatism, triggered activity, reflection, and other)
the summarized syllabus for the HR specialist, but with specific
8. Impulse formation and conduction within the heart (sinus
knowledge of HR implantable devices (Cardiac Pacing, ICDs, and
function, sinoatrial conduction, atrial conduction and refrac-
other), as follows:
toriness, AV nodal and His Purkinje physiology, ventricular
conduction and refractoriness, and other) 1. Historical perspectives of HR implantable devices
9. ECG and EP (cardiac activation, responses to electrical stimu- 2. Conventional and non-conventional indications of HR implan-
lation and to drug administration, EP diagnosis, and other) of table devices (bradiarrhytmias, tachycarrhythmias, heart failure
normal HR and electrical impulse conduction and cardiomyopathies, sleep apnoea syndrome, and other)
10. ECG and EP (induction, cardiac activation, responses to 3. Electricity and electronics related to physic laws, waveforms,
electrical stimulation and to drug administration, cardiac parameters, measurements, and units
activation, EP diagnosis, and other) of the different types 4. Haemodynamics and physiology of cardiac pacing and
and variants of sinus and AV node and His-Purkinje defibrillation
impulse formation and conduction defects including sick 5. HR implantable devices and components:
sinus syndrome, AV block, intraventricular conduction

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5.1 Models and modes (international codes, other)
blocks, and autonomous system mediated disorders
5.2 Generators (battery, capacitors, circuits, and other)
(carotid sinus hypersensitivity, neurocardiogenic syndromes,
5.3 Leads and arrays (material, structure, type, electrodes,
and other)
coils, connector/adapters, and other)
11. ECG and EP (induction, termination, cardiac activation,
5.4 Sensors
responses to electrical stimulation and to drug administration,
5.5 Ancillary materials (sheaths, guidewires, and other)
EP diagnosis, and other) of the different types and variants of
6. Implantation and replacement/extraction techniques (surgery,
sinus node and atrial arrhythmias, including atrial ectopy, atrial
lead implantation/replacement techniques, and other)
escape and accelerated rhythms, sinus node and atrial tachy-
7. Fluoroscopy, angiography, and other navigation techniques
cardias, atrial flutters, and atrial fibrillation
8. Electrogrammes, markers, intervals, Holter features, and other
12. ECG and EP (induction, termination, cardiac activation,
storage and diagnosis capabilities
responses to electrical stimulation and to drug administration,
9. Device testing at implantation (pacing and sensing measure-
EP diagnosis, and other) of the different types and variants
ments and parameters, arrhythmia induction and termination,
of junctional arrhythmias, including junctional ectopy, junc-
and other)
tional escape and accelerated rhythms, and junctional
10. Rhythm and device detection programming:
tachycardias
10.1 Detection zones
13. ECG and EP (induction, termination, cardiac activation,
10.2 Refractory and blanking periods
responses to electrical stimulation and to drug administration,
10.3 Tachycardia discrimination (single and dual chambers)
EP diagnosis, and other) of the different types and variants of
10.4 AV synchrony, hysteresis, automatic mode change
ventricular arrhythmias, including ventricular ectopy, ventricu-
10.5 Rhythm and device problem detection alarms
lar escape and accelerated rhythms, ventricular tachycardias,
11. Rhythm therapy programming:
ventricular flutter, and ventricular fibrillation
14. ECG and EP (induction, termination, cardiac activation, 11.1 Cardioversion and defibrillation (modes, parameters,
responses to electrical stimulation and to drug administration, algorithms and automatisms, and other)
EP diagnosis, and other) of the different types and variants of 11.2 Antitachycardia pacing (modes, parameters, algorithms
AV accessory pathways and AV accessory pathways mediated and automatisms, and other)
arrhythmias, including ectopy, escape and accelerated 11.3 Antibradicardia pacing (modes, parameters, algorithms
rhythms, and tachycardias and automatisms, and other)
15. ECG and EP (induction, termination, cardiac activation, 11.4 Haemodynamic and resynchronization pacing (modes,
responses to electrical stimulation and to drug administration, parameters, algorithms and automatisms, and other)
EP diagnosis, and other) of the different types and variants of 12. Follow-up:
inherited rhythm disorders (long and short QT syndromes, 12.1 Longevity estimation and general and interval
Brugada syndrome, catecholaminergic polymorphic ventricular recommendations
tachycardia, and other) 12.2 Device parameters to measure (sensing, pacing,
16. Ablation techniques (catheters, energies, biophysics, mapping, defibrillation, lead integrity, battery life, arrhythmia epi-
anatomical substrates, success predictors, and other) of the sodes, and other)
different rhythm disorders previously stated 12.3 Normal and abnormal ECG at follow-up in HR device
17. Complications and adverse effects of EP studies and recipients
ablation: pathophysiology, diagnosis, prevention, and 12.4 Memory loop/channels markers
management 12.5 Invasive and non-invasive evaluation of pacing,
18. Professional, legal, ethical, and socioeconomical issues cardioversion-defibrillation, and cardiac synchronization
iii6
Table 1 Anatomy of the heart and the conduction system

Objectives Knowledge Skills Behaviours and attitudes

Become familiar with both the arterial and Describe the anatomy of the conduction system Demonstrate knowledge of the conduction Discuss and accept advice from other specialized
venous vascular system distributions, especially and the propagation of the electrical impulse system by properly performing physicians, such as cardiac surgeons, pathologists,
concerning the aspects aimed at gaining through the heart electrophysiological studies, ablation procedures, radiologists, or paediatric physicians in
peripheral access and device implantations anatomically complex cases
Outline the anatomy of the main components of
Be able to correlate the anatomy of the heart the peripheral venous system commonly used for Demonstrate knowledge of the aorta and
with images resulting from the main cardiac vascular access during PM/ICD implantation coronary artery systems
imaging techniques (echocardiography,
cardiovascular magnetic resonance, cardiac Outline the anatomy of the main components of Demonstrate knowledge of the coronary venous
computed tomography, other) and EP 3D the peripheral arterial and venous systems system
navigators commonly used for vascular access during
electrophysiological studies and ablation Demonstrate knowledge of the peripheral
procedures venous system by correctly gaining peripheral
access
Outline the anatomy of the coronary venous
system, especially in relation to electrocatheter To be able to select the appropriate vascular
and CRT lead placement access based on the type of procedure and the
specific characteristics of the patient

J.L. Merino et al.

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Core curriculum for the heart rhythm specialist iii7

12.6 Telemonitoring

Appreciate the limitations and the potential risks

electrophysiological properties of the heart and

therapy for the patients by weighing up the risk
13. Pathophysiology, diagnosis, prevention, and management of

Select the appropriate diagnostic procedure or

complication:

of certain antiarrhythmic drug therapies in

structural heart diseases in relation to the

Appreciate the importance of coexisting
13.1 Related to implantation and surgical techniques (pneu-

the most likely arrhythmia mechanism

mothorax, bleeding, thrombosis, infection, and other)
and benefits in relation to heart EP

relation to their ionic mechanisms

13.2 Related to electrode, arrays, or generator dysfunction
Behaviours and attitudes

(connection, dislocation, isolation defects, conductor

defects, and other)
13.3 Related to inappropriate model selection and program-
ming (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
Demonstrate knowledge of ion channels function

nervous system influences on heart EP and heart

Demonstrate knowledge of specific mechanisms
Demonstrate knowledge of general physiology

14. Professional, legal, ethical, and socioeconomical issues

of arrhythmias, syncope, and sudden death

Demonstrate knowledge of the autonomic

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General learning objectives
Individual training in HR management requires the basic skills of a
and regulation and cellular EP

good physician. He/she should have a solid background in all

aspects of general medicine, which can provide the basis for special-
ized arrhythmia care. Cardiac arrhythmia management is recognized
as a particularly challenging field of expertise. The complexity of
and heart EP

arrhythmia mechanisms and the consequent complexity of under-

arrhythmias

standing them and the management options are challenging. This jus-
Skills

tifies 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
Ion channels function and regulation and cellular

Autonomous system influences on heart EP and

activity, focal reentry, macroreentry, and other

Normal and abnormal EP of the heart and the

study design and statistical principles. In addition, a thorough knowl-

automatism, abnormal automatism, triggered

Specific mechanisms of rhythm disorders,

edge of the principles of clinical ethics and clinical and research gov-
Basic mechanisms of arrhythmias: normal

ernance 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,
syncope, and sudden death

development of patient communication and ‘people’ skills is highly

important. Finally, administration of clinical practices requires a
major thoracic vessels
Table 2 General physiology and heart electrophysiology

broad set of administrative skills. The individual responsible for

heart arrhythmias

service management needs to equip him/herself with an understand-

Knowledge

mechanisms

ing 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
EP

equipment, and undertake appraisal.

ion channels and the effects of ionic disbalance on
Have a good understanding of the cardiomyocyte

The knowledge that trainees require to become competent in the

Have basic understanding of general physiology

Have a good understanding of the effect of the

and a deep understanding of cardiac and major

management of patients with HR disorders is defined in the Core Syl-

cardiac EP vessels in normal subjects and in

labus section. However, the Core Curriculum needs to establish what

autonomic nervous system on the heart

the trainee should be able to do at the end of the training period, that
is, the general learning objectives. This section presents tables
patients with cardiac arrhythmias

(Tables 1–12) of the main learning objectives to achieve in the differ-

ent areas of HR management together with the knowledge, the prac-
tical skills, the behaviour, and the attitudes the trainee should have
achieved at the end of the training period.
Objectives

cardiac EP

Training requirements and plan

This section details the minimal requirements of the training pro-
gramme for HR specialists. Following this training programme,
iii8
Table 3 Diagnostic procedures and techniques: general

Objectives Knowledge Skills Behaviours and attitudes

...........................................................................................................................................................................................................................................
Select and indicate correctly Basic knowledge of techniques, modalities, indications, Choose the non-invasive technique for specific clinical situations, Choose the diagnostic techniques,
the different non-invasive interpretation, and the diagnostic yield of general cardiology including a thorough understanding of the Bayesian approach modalities, and protocols in a clinically
diagnostic techniques used in non-invasive and imaging techniques such as: useful and cost-effective way, avoiding
heart rhythmology Interpret the results of the general cardiology non-invasive and over- and under-utilization of tests
Exercise testing imaging techniques
Be able to perform and X-ray Recognize and remain up-to-date with
interprete the different Echocardiography Implement and interpret the non-invasive rhythmology developments in the field of non-invasive
non-invasive diagnostic Cardiac magnetic resonance imaging techniques diagnostic procedures
techniques specifically related Cardiac-computed tomography imaging
to heart rhythmology Nuclear cardiology Transoesophageal recording catheter placement techniques and Explain to patients the implications of the
Blood sampling and other laboratory analysis interpretation of recording findings and stimulation responses results of the various diagnostic tests in an
Be able to integrate the results Genetic analysis understandable manner
of the different diagnostic Manage the non-invasive rhythmology technique equipment
techniques into the individual Extensive knowledge of techniques, modalities, indications, (ECG machines, ECG monitoring systems and recorders, tilt test Be able to cooperate with
care of patients with rhythm interpretation, and the diagnostic yield of non-invasive system, etc.) echocardiography cardiologists,
disorders rhythmology techniques such as: radiologists, and other non-invasive
Evaluate each diagnostic procedure in the clinical context and in technique physicians when appropriate
Clinical evaluation (history, physical exam) of patients with reference to other non-invasive or invasive techniques
rhythm disorders
Electrocardiography:
– Conventional 12-lead ECG
– ECG monitoring (Holter, event monitoring,
implantable event, and loop monitoring)
– Signal-averaged ECG and body surface mapping
– Heart rate variability and baroreflex sensitivity
– T-wave and micro-T-wave alternants
– ECG-drug infusion tests (flecainide, etc.)
– Transoesophageal electrical recording
Autonomic nervous system evaluation:
– Carotid sinus massage
– Tilt testing

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Core curriculum for the heart rhythm specialist
Table 4 Diagnostic procedures and techniques: invasive cardiac electrophysiology

Objectives Knowledge Skills Behaviours and attitudes

Complications and adverse effects of EP studies:

patho-physiology, diagnosis, prevention, and management

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iii10
Table 5 Therapies: general

Objectives Knowledge Skills Behaviours and attitudes

Basic knowledge of indications, techniques, Recognize and remain up-to-date with developments
performance, and response interpretation of in the field
other therapy modalities in heart rhythmology

Arrhythmia surgery

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Core curriculum for the heart rhythm specialist
Table 6 Therapies: catheter ablation

Objectives Knowledge Skills Behaviours and attitudes

...........................................................................................................................................................................................................................................
Understand the anatomical substrates that govern the Normal and abnormal anatomical formations Patient and procedure-type selection for specific Develop a critical attitude towards
approach to catheter ablation of cardiac arrhythmias that govern the approach to intracardiac catheter arrhythmia management strategies/targets ablation techniques
placement
Master and understand how to demonstrate/diagnose/ Performance of both simple and complicated Develop a correct attitude to an
confirm any given arrhythmia mechanism and the critical Intracardiac catheter positioning and protocols of extrastimulation/pacing/catheter interventional procedure, particularly
components of its mechanism by a combination of electrophysiological pacing techniques that manipulation that generate intracardiac electrogram the appreciation of sterility and
pattern recognition and electrical interaction with the elucidate the arrhythmia mechanism recordings; the examination of which will identify the antibiotic usage
arrhythmia mechanism (e.g. extrastimulation/ arrhythmia mechanism
entrainment) Electrogram activation patterns and their Commit to the audit of long-term
changes in response to planned Use of imaging techniques that allow selection of outcomes, including infection and
Understand the equipment and technologies and their electrophysiological perturbations that allow catheters/procedural equipment and a technical procedural complications
operation that facilitate electrophysiological deductive reasoning to determine arrhythmia approach sufficient for the safe and expeditious
interventions mechanism diagnosis/treatment of cardiac arrhythmias Foster a team approach to diagnostic/
interventional catheter ablation
Master an understanding of catheter placement for Use of stimulators, catheters, mapping systems, Practical competency in catheter deployment/ procedures including a close
arrhythmia mechanism elucidation and ablation and lesions creation technologies sufficient for manipulation and interaction with stimulators/ relationship with cardiac technicians
their safe application in patient treatment mapping technologies/lesion creating technologies
(e.g. radiofrequency generator) Work closely with other health care
Use of 3D non-fluoroscopic navigation system professionals as necessary: cardiac
(Carto, Ensite, etc.) Practical competency in use of mapping technologies/ technicians, cardiologists, infection
lesion creating technologies (e.g. radiofrequency control, care of the elderly,
Basic knowledge about remote navigation generator) sufficient to allow accurate mapping/ neurologists, etc.
characterization of the arrhythmia mechanism and,
Angiography performance (e.g. pulmonary veins) when appropriate, safe lesion creation for the Educate patients about the treatment
purpose of ablation options available to them and explain
the treatment strategies

Appreciate the psychological impact of

the patient’s arrhythmia illness on the
patient and his/her family, and manage it
sensitively

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iii12
Table 7 Therapies: implantable devices: pacemakers

Objectives Knowledge Skills Behaviours and attitudes

...........................................................................................................................................................................................................................................
Have a good understanding of the The principles of pacing, the engineering of PM and of Select the appropriate patient for implantation Correct attitude to a surgical approach, particularly
fundamentals of cardiac stimulation both pacing leads with respect to sterility and antibiotic usage
electrically and the engineering involved Perform safe implantation of single and dual
The cardiac conduction system and its disease chamber PMs via the cephalic, subclavian, or Foster a team approach to pacing including a close
Have detailed knowledge of pacing device processes internal jugular approaches relationship with cardiac technicians
and PM lead characteristics
The influence of drugs on bradiarrhytmias Perform safe intravascular catheter Commit to the audit of long-term outcomes
Have detailed knowledge of the published manipulation including infection and lead complications
guidelines for implantation of PM and Cardiac and thoracic anatomy, especially with respect
clinical indications to venous access, including the cephalic, subclavian, and Develop surgical skills in opening, manipulating, Develop a critical attitude towards a safe pacing
internal jugular vein approach and closing wounds programme in the hospital and to support patients
Have detailed knowledge of the in their community with adequate pacing follow-up
haemodynamics of cardiac pacing, and the The indications and international and national Proper insertion and care of temporary pacing
device and mode selection guidelines for correct PM prescription, including pacing wires Educate patients about the treatment options
mode available to them and explain the treatment
Understand the implantation technique, Manage peri-procedural complications, e.g. strategies
and the cardiac and thoracic anatomy The safe implantation of PMs including the operating cardiac tamponade, and pneumothorax
environment and antibiotic usage Work closely with other health care professionals
Master safe sterile techniques for all Competent programming of PMs including the as necessary: cardiac technicians, cardiologists,
procedures Management of complications of PM implantation programming of sensors infection control, care of the elderly, neurologists,
including pneumo-haemothorax and lead perforation etc.
Have detailed knowledge of the Competent programming of newer algorithms
programming of modern PM following Management of lead problems and programming issues for atrial tachycardia prevention and Appreciate the psychological impact of the patient’s
implantation including troubleshooting specifically related to leads termination, and for minimizing ventricular arrhythmia illness on the patient and his/her family,
pacing and manage it sensitively
Have detailed knowledge of the PM Modern pacing systems and troubleshooting
malfunction including interference, and Manage of PM malfunction and troubleshooting
PM-mediated tachycardia Rate-modulated pacing and sensor technology

Have detailed knowledge of the regulatory Medico-legal issues concerning consent, provision of
and legal aspects information, and driving restrictions

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Core curriculum for the heart rhythm specialist
Table 8 Therapies: implantable devices (implantable cardioverter-defibrillators)

Objectives Knowledge Skills Behaviours and attitudes

...........................................................................................................................................................................................................................................
Have a good understanding of the fundamentals of The principles of defibrillation and the engineering of Select the correct patient for Appreciate the importance of informed
cardiac defibrillation, both electrically and the device and of defibrillating leads of the medical treatment of implantation consent and the need to explain lifestyle
engineering involved tachyarrhythmias including interaction of drugs with issues and driving restrictions to the
defibrillation and arrhythmia cycle-length Carefully investigate patients prior to patient
Have detailed knowledge of defibrillating device and implantation (including whether or not
lead characteristics The pro-arrhythmic effect of antiarrhythmic drugs revascularization is required) Correct attitude to a surgical approach
particularly with regards to their effect on left ventricular particularly with regards to sterility and
Have detailed knowledge of the published guidelines for function Explain the procedure, the possible antibiotic usage
clinical indications of ICDs complications, and the possible effects
Cardiac and thoracic anatomy, especially in respect of on the patient’s lifestyle to the patient Appreciate the importance of
Understand the implantation technique and the cardiac venous access including the cephalic, subclavian, and and to his/her relatives team-working with nursing, technical,
and thoracic anatomy, and master safe sterile technique internal jugular vein approach radiographic, anaesthetic, and, if
for all procedures Assess the anaesthetic/sedation needs of appropriate, industrial staff
The indications and international and national guidelines for the patient before and during the implant
Have detailed knowledge of the programming of ICDs correct ICD implantation procedure Appropriate self-confidence and
following implantation: providing zone of ventricular recognition of limitations
tachycardia at various rate, discriminators between Management of complications of ICD implantation Assess whether a single, dual, or triple
ventricular and supraventricular tachycardia, including pneumo-haemothorax and lead perforation chamber (i.e. biventricular) device is best Commit to the audit of long-term
appropriate use of ATP and shock therapy, and suited to the patient outcomes including infection and lead
minimizing ventricular pacing Management of lead problems complications
Perform the implant procedure
Have detailed knowledge of troubleshooting including Management of complications during long-term follow-up competently with an acceptably low Develop a critical attitude towards a safe
the recognition of drug-device interaction, and complication rate preventive programme in the hospital and
appropriate and inappropriate shocks Medico-legal issues concerning consent, provision of to support patients in their community
information, and driving restrictions Perform appropriate tests of pacing, with adequate ICD follow-up
Have detailed knowledge of ICD malfunctions and sensing, and defibrillation safely and
device and leads complication thoroughly during the implant Educate patients about the treatment
options available to them and explain the
Have detailed knowledge of the regulatory and legal Competent programming of the device treatment strategies
aspects in the pre-discharge phase
Work closely with other health care
Perform routine follow-up of ICD professionals as necessary: cardiac
patients technicians, cardiologists, care of the
elderly, neurologists, etc.
Manage ICD malfunctions and
troubleshooting Appreciate the anxiety that patients suffer
with an ICD

Appreciate the psychological impact of the

patient’s arrhythmia illness on the patient
and this/her family, and manage it
sensitively

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iii14
Table 9 Therapies: implantable devices (multisite ventricular pacing for resynchronization)

Objectives Knowledge Skills Behaviours and attitudes

...........................................................................................................................................................................................................................................
Evaluate the proper medical Pathophysiology complications, diagnosis, Be able to select appropriate patients for CRT Take a sensible, professional attitude to CRT, learn under supervision
therapy in patients with heart prevention, and management with appropriate requests for advice
failure Be able to consent a patient in a balanced and
Historical of techniques available to identify informed way about the success rate, the risks, Consent patients sensitively with an objective assessment of
Appreciate the adjunctive role of patients likely to benefit from CRT and to be and the benefits of CRT likelihood of benefit
CRT in the management of aware of limitations of these techniques
patients with heart failure Be able to proceed with a CRT implant in a safe Appreciate the importance of team-working with nursing, technical,
Be able to determine when an ICD back-up is and logical manner radiographic, anaesthetic, and, if appropriate, industrial staff
Have a detailed knowledge of the required
anatomy of the coronary venous Be able to recognize the nature of implant Work closely with other health care professionals as necessary being
system Anatomy of the coronary venous system difficulties and to take the appropriate action to aware of the importance of a multi-disciplinary team in heart failure
overcome these management and in maximizing benefit of CRT: cardiac technicians,
Undertake implantation of CRT All the equipment available, including that for cardiologists, infection control, care of the elderly, internal medicine
devices with a high probability of implantation and also for subsequent Appreciate when an alternative technique or specialists, etc.
success programming approach may be required (e.g. surgical device
implantation) Deal appropriately with patients in whom CRT implantation has not
Recognize and deal with implant Relative benefits of different leads and devices been effective
or device behaviour Be able to programme the devices
complications Implantation techniques and how to deal with appropriately, and to advise on optimization Appreciate the psychological impact of the patient’s illness on the
common problems using recognized techniques such as patient and his/her family, and manage it sensitively
Be able to optimize therapy echocardiography
delivery including proper Potential complications
programming of stimulation Be able to analyse and properly use the
Potential of the diagnostic data stored in the diagnostic data coming from the implanted
Be able to analyse and properly device’s memory device
use the diagnostic data coming
from the implanted device Medico-legal issues concerning consent and
provision of information

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Core curriculum for the heart rhythm specialist
Table 10 Arrhythmic disorders

Objectives Knowledge Skills Behaviours and attitudes

Arrhythmia epidemiology and prognosis

Arrhythmia diagnosis management

Arrhythmia therapy management

ESC guidelines

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iii16
Table 11 Arrhythmogenic diseases and syndromes

Objectives Knowledge Skills Behaviours and attitudes

Arrhythmia epidemiology, prognosis, and risk

evaluation

Arrhythmia diagnosis management

Arrhythmia therapy management

ESC guidelines

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Core curriculum for the heart rhythm specialist
Table 12 Professional, legal, and socioeconomical aspects

Objectives Knowledge Skills Behaviours and attitudes

Establish solid concepts of ethics in professional

practice

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iii18 J.L. Merino et al.

the trainee will entitle recognition of theoretical and practical com- more than one centre may be responsible for the teaching pro-
petency in invasive EP and HR management device implantations gramme although each centre is encouraged to develop a struc-
and follow-up. At the end of the training programme, the trainee tured teaching programme dealing with the management of HR
should be able to treat independently patients with HR disorders. problems. In addition, simulator training should be encouraged
The duration of training, the training plan, and the certification prior to entering the programme in order to shorten the learning
process are described in this section. curve for procedures such as coronary sinus lead placement.
The training plan should include clinical activities and practical
Training duration training together with theoretical educational activities, and
Due to the complexity of treating patients with HR disorders and research activities and education. During the training period, trai-
the difficulty of performing catheter ablation procedures and nees should attend and participate in weekly meetings reviewing
device implantations independently as the first operator, the dur- topics and discussing patients, indications, results, and procedural-
ation of the training period should be for a minimum of 2 years. related complications. In addition, the trainee should attend at least
During this period, the trainee must be involved in all aspects of one official international subspecialty meeting of a scientific society
HR management, including the research and educational activities in the field. The trainee must be involved in research activities in
of the teaching department. The trainee should not only fulfil the HR field and should present at least one scientific abstract at
the criteria concerning the procedure numbers, but should also a national or international meeting in the field during the training
undergo a final evaluation. Such an evaluation has been developed period.

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by the EHRA, which presently requires the trainee to take and pass During the 2 year training period, the trainee should participate
the EHRA accreditation exams (invasive EP and cardiac pacing and in the HR training programme for at least 80% of the working
ICDs) in order register as a HR specialist in this association. Finally, hours (based on full-time employment). Although in some cases,
the programme director should provide a written statement con- it may be possible to expand the training period if the participation
cerning the ability of the trainee to treat patients with cardiac drops below 80%, this should remain an exception. During the
arrhythmias at the end of the training period. Assessment of com- training period, dedication to the different clinical activities
petency should be closely monitored by the programme director should be distributed as follows:
and the teachers in order to evaluate the progress of the trainee
during the training period. 1. Outpatient clinic: 10% of the training period
2. Device (ICD, CRT, and PMs) follow-up: 10% of the training
Trainee requirements period
The minimum education, training, experience, and skills necessary 3. Device (ICD, CRT, and PMs) implantations: 10% of the training
to perform HR procedures are designed for trained or trainee car- period
diologists. A cardiology background is necessary not only to 4. Invasive EP: 40% of the training period.
master the technical aspects, but also to verify the indications
and contraindications, to conduct investigations, and to give an Based on a 2 year training period (assuming that basic cardiology
accurate and comprehensive interpretation of the clinical data. training is completed), training should be distributed as follows:
Therefore, the trainee should be a registered cardiologist or
Months 1– 4
should fulfil the requirements of a general cardiologist set in the Outpatient clinic
core curriculum of the ESC in order to enter the programme During this period, the trainee will treat patients at the outpatient
accordingly. However, because official recognition as a cardiology clinic under close supervision of one of the trainers. It should be a
specialist is delayed several years after the end of cardiology train- dedicated outpatient clinic dealing mainly with patients with
ing in some European countries, trainees who finalize their training arrhythmias. The indication to refer a patient for catheter ablation
programme in HR management and who will become a registered or device implantation should be discussed with the trainer.
cardiologist in less than 5 years after that date will be recognized as
registered HR specialists by the EHRA.
Device follow-up
Training plan During this period, the trainee will learn to perform the technical
The trainee should follow a structured teaching programme follow-up of device patients.
and the learning objectives detailed in the previous section. Furthermore, the trainee must become familiar with the differ-
The teaching program should include the development of appro- ent devices in the HR department.
priate behaviours and attitudes together with the knowledge and
manual skills of the catheter, recording techniques, and the differ-
ent systems used in the treatment of patients with HR problems. Arrhythmia clinic
The programme must be comprehensive and completion of the During this period, the trainee will be responsible for the arrhythmia
training in one centre is recommended. However, if a centre is clinic under close supervision of one of the trainers. Special attention
not able to develop a complete teaching programme, it should should be paid to the development of the HR clinician. Furthermore,
work with other centres to complete its lacking activities or to the trainee should become familiar with the psychological effects
allow the trainee to participate in teaching programmes developed that an ablation procedure or device implant can have on the
by EHRA or other recognized educational activities. Therefore, patient and the patient’s relatives.
Core curriculum for the heart rhythm specialist iii19

Interventions/diagnostic procedures In addition, the trainee should be able to trouble shoot

During this period, the trainee should perform arterial and venous device-related problems.
access according to the Seldinger technique.
Furthermore, the trainee should be trained to situate diagnostic Arrhythmia clinic
catheters in the different chambers of the heart. The trainee During this period, the trainee will be responsible for the arrhyth-
should become familiar with the EP equipment and the different mia clinic under supervision of one of the trainers.
monitoring systems used during these procedures.

Device implantations Interventions/diagnostic procedures

The trainee should perform regular PM implants and assist during During this period, the trainee should perform diagnostic pro-
the implantation of ICD/CRT devices. cedures and assist during ablation procedures. Furthermore, the
trainee should be able to perform a periocardiocentesis in case
Emergency department and in-hospital emergency of an emergency after training.
During this period, the trainee should participate in the manage-
ment of patients with urgent HR disorders under close supervision. Device implantations
During this period, the trainee should perform regular PM implants
Months 5 –8 independently and act as operator during ICD implantations under

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Outpatient clinic supervision. He/she will assist during CRT implantation.
During this period, the trainee will treat patients at the outpatient
clinic under close supervision of one of the trainers. In addition, the
Emergency department and in-hospital emergency
trainee should be trained in non-invasive EP (like Holter monitor-
During this period, the trainee will participate in the emergency
ing, ECG recording, and neuro-humoral testing).
department/in-hospital emergency duty service under close
Device follow-up supervision.
During this period, the trainee will learn to perform the technical
follow-up of device patients. Months 13 –16
In addition, the trainee must become familiar with the different Outpatient clinic
devices in the HR department. The trainee should be able to During this period, the trainee will treat patients at the outpatient
perform routine technical follow-ups independently. The trainee clinic independently and should be able to decide if patients should
should learn to troubleshoot device-related problems under be referred for catheter ablation or device implantation.
close supervision.
Device follow-up
Arrhythmia clinic During this period, the trainee will supervise the follow-up pro-
During this period, the trainee will be responsible for the arrhyth- gramme. Furthermore, the trainee should be able to solve most
mia clinic under the supervision of one of the trainers. device-related problems independently.

Interventions/diagnostic procedures
During this period, the trainee must be able to perform simple Arrhythmia clinic
diagnostic procedures. During this period, the trainee will supervise the arrhythmia clinic
(under the supervision of the programme director).
Device implantations
During this period, the trainee should perform regular PM implants Interventions/diagnostic procedures
and assist during implantation of ICDs and CRT devices. During this period, the trainee must perform ablation procedures
as the first operator and assist during complex procedures, such
Emergency department and in-hospital emergency as ventricular tachycardia ablation, atrial fibrillation ablation, and
During this period, the trainee may participate in the emergency atypical atrial flutter ablation. Furthermore, the trainee should
department/in-hospital emergency duty service under supervision. be able to perform most diagnostic procedures independently.
The trainee should become familiar with transseptal punctures.
Months 9 –12
Outpatient clinic
Device implantations
During this period, the trainee will treat patients at the outpatient
During this period, the trainee should perform regular PM and ICD
clinic independently, but should discuss all patients with one of the
implants and become the first operator in CRTs implantations.
supervisors. Furthermore, the trainee should be able to analyse
Holter recordings and ECGs independently.
Emergency department and in-hospital emergency
Device follow-up During this period, the trainee will participate in the emergency
During this period, the trainee should perform the technical department/in-hospital emergency duty service under supervision
follow-up of device patients. of the programme director.
iii20 J.L. Merino et al.

Months 17 –20 Emergency department and in-hospital emergency

During this period, the trainee should be trained to perform During this period, the trainee will participate independently in the
complex ablation procedures. Furthermore, the trainee should emergency department/in-hospital emergency duty service.
be able to perform transseptal punctures as the first operator.

Months 21 –24 Indicative number of procedures

Outpatient clinic
The numbers of procedures performed have been used for a long
During this period, the trainee must be able to supervise the out-
time as a measure of training. While recognizing the crude nature
patient clinic (under the supervision of the programme director).
of the number of procedures as an assessment method, the use of
the indicative number of procedures is a useful means of ensuring
Device follow-up sufficient exposure to a technique. This section details the
During this period, the trainee must be able to supervise the minimum number of procedures recommended to be performed
device outpatient clinic. 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 Curricu-
Arrhythmia clinic
lum for the General Cardiologist,4 are complementary to them,

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During this period, the trainee will be responsible for the arrhyth-
and are defined as follows:
mia clinic.
– Level I: experience of selecting the appropriate diagnostic
modality and interpreting the results or choosing an appropriate
Interventions/diagnostic procedures
treatment for which the patient should be referred. This level of
During this period, the trainee should be able to perform all abla-
competence does not include performing a technique.
tion procedures as first operator.
– Level II: practical experience, but not as an independent oper-
ator, including assisting in or performing a particular technique
Device implantations or procedure under the guidance of a superior.
During this period, the trainee will perform regular PM implants – Level III: is able to independently perform the technique or pro-
and ICD and CRT-D/PM implantations. cedure unaided.

Table 13 Minimum recommended procedural numbers and levels of competence in non-invasive techniques to be
achieved by the HR specialist during training

Technique Number Level of competence Comments

...............................................................................................................................................................................
Holter ECG monitoring (external) 50 III –
ECG event recording 5 III –
Pharmacological test, autonomic system manoeuvres, and tilt test 25 III –
Pacemaker follow-up/programming 250 III –
ICD follow-up/programming 100 III –
CRT follow-up/programming 50 III –

Table 14 Minimum recommended procedural numbers and levels of competence in invasive techniques to be achieved
by the HR specialist during training

Technique Number Level of competence Comments

...............................................................................................................................................................................
Diagnostic invasive electrophysiological studies 200 III 50 as the primary operator
(as a standalone procedure or prior to an ablation procedure)
Percutaneous catheter ablation 150 III 35 as the primary operator
Transseptal catheterization 10 III 5 as the primary operator
Pacemaker implantation 50 III 30 as the primary operator
ICD implantation 30 III 15 as the primary operator
CRT implantation 20 III 10 as the primary operator
Core curriculum for the heart rhythm specialist iii21

The trainee should review at least 1000 12-lead ECGs during – AV conduction ablation
the training period in addition to the .1000 that he or she – Ventricular tachycardia: idiopathic and in patients with structural
should have had reviewed during the cardiology specialty training. heart disease
In addition, the trainee should gain basic knowledge (level of com-
The training centre should perform yearly at least 250 invasive
petence I) in ECG-based techniques, including T-wave alternant
electrophysiological diagnostic procedures, 200 catheter ablation
analysis, body-surface potential mapping, and heart rate variability.
procedures, 200 PM implantations/replacements, 50 ICDs implan-
The trainee should also be familiar (level of competence I) with
tations/replacements, and 20 CRTs implantations/replacements.
surgery for HR disorders. The recommended procedural
numbers and the levels of competence for the rest of the HR pro- Educational activities
cedures are presented in Tables 13 and 14. The training centre should organize regular theoretical educational
activities on a weekly basis, such as meetings reviewing topics and dis-
Training centre and trainer cussing patients, indications, results, and procedural related compli-
cations. In addition, the training centre must encourage the trainee’s
requirements attendance at official international subspecialty meetings.
Training centre requirements
Formal training in HR management must be carried out in a centre Research activities

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that is recognized and accredited by an official organization, such as A training centre should maintain a minimum level of scientific
the EHRA, as a HR Subspecialty training centre. The training centre activity and interest in heart rhythmology, which is endorsed by
should be integrated within a full-service cardiology department, the presentation of at least three related scientific communications
which includes an interventional unit, a cardiac imaging depart- at an EHRA recognized official subspecialty congress (Europace,
ment, a heart-failure unit, and a cardio-surgical unit. The institution European Society of Cardiology congress, American Heart Associ-
must be a training centre for general cardiologists and a recognized ation scientific sessions, American College of Cardiology scientific
centre (by the health authorities or according to national laws) for sessions, HR Society congress, and European national societies
performing all arrhythmia and device-related procedures with the annual congresses) during the previous 3 years and the publication
only exception of arrhythmia surgery. Specific arrhythmia surgery of at least one scientific article related to heart rhythmology in
programmes have decreased during the last two decades and a journal with an objective ‘impact factor’ during the previous
nowadays few centres perform surgery for ventricular tachycardia 3 years.
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 Infrastructure and equipment
arrhythmia surgery. The centre must have access to at least one The training centre should be equipped with the state-of-the-art
dedicated and fully equipped EP catheterization laboratory, it equipment in order to offer current technology treatment
must record procedural related data, and it and must have a com- approaches. The centre should have the following available on-site:
plication registration system. – Up-to-date monitoring equipment.
The training centre must employ at least two fully trained, – Modern catheterization laboratories: as x-ray exposure is a
advisable HR specialists, who should be recognized (accredited) serious issue in invasive EP and device implantation procedures,
by the EHRA. Both of them must be actively involved in the field X-ray systems allowing dose-reduction and image optimization
of HR management for at least 70% of the time (based on a full- should be used. Furthermore, X-ray exposure should be As
time employment). The programme supervisor should be a fully Low As Reasonably Achievable (ALARA principle). X-ray
trained HR specialist recognized by the EHRA and who has at exposure (in mSv or Gy) should be recorded during each pro-
least 5 years of experience in the field. In addition, the training cedure. Personal protection should be available. Only trained
programme staff should be active in clinical research related to personnel (according to national laws) should be allowed to
the field of HR management. operate X-ray equipment.
– Due to the risk of haemodynamic problems and the risk of ven-
Clinical practice activities: procedures tricular arrhythmias, each catheterization laboratory should be
equipped with resuscitation equipment and the possibility to
and numbers
sedate and monitor patients. Preferably, it should be possible
The training centre should perform PM, ICD, and CRT device
to deliver deep anaesthesia.
implantation and replacement, invasive electrophysiological pro-
– It should be possible to perform an emergency periocardiocent-
cedures, and the following catheter ablation procedures on a
esis. Operators should have experience of this procedure.
regular basis:
– A multichannel recording system (at least a 16-channel recording
– Accessory pathway mediated tachycardias system) and a multi-programmable stimulator should be available
– AV nodal re-entrant tachycardia/junctional tachycardia to perform diagnostic and catheter ablation procedures.
– Ectopic atrial tachycardia – 3D electro-anatomical mapping is a prerequisite to perform
– Atrial flutter from the right and the left atrium complex ablation procedures (such as ablation of atrial fibrilla-
– Atrial fibrillation tion or ventricular tachycardia) and it should be available.
iii22 J.L. Merino et al.

– 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
Figure 2 Accreditation certification title issued by the EHRA
a multislice-CT scanner to allow evaluation of coronary pathol-

Downloaded from europace.oxfordjournals.org at KU Leuven on October 4, 2010

for professionals trained in implantable cardiac rhythm devices
ogy and to reconstruct 3D anatomy. and who have passed a theoretical examination.
– 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 pro- practical competence of the trainee and to promote continuous
gramme should be operational. At least one heart failure improvement of the training programmes. The assessment
specialist should be involved in the decision-making process methods should include reports by the training programme
before the actual CRT implant is carried out. Preferably, the supervisor and the national society HR organizations, a logbook
centre has a heart failure outpatient clinic. of procedures, written examinations, and assessment of profes-
sionalism. In addition, the assessment process should include an
Certifying as a training centre appeal procedure, as an additional quality control of the system
Training centres should comply with the National Quality insurance provided by their participants, and a revocation procedure for
programme. The National Working Group on Arrhythmias should accredited professionals or centres that act incompetently or in
endorse the training centre and trainers. 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 assessment training in this field of cardiology, but for objective certification of
Assessment of the trainee and the training programmes is essen- the qualification of training personnel and training centres, with
the guarantee of required quality from a strictly professional
tial, both to guarantee a minimum level of knowledge and
and technical point of view. The implantation of such an accred-
itation 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 consen-
sus 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 accredi-
tation of centres and professionals by verifying the candidates’ cre-
dentials, log books and merits, evaluating and verifying the centre
and the candidates’ professional competence, and implementing
and holding accreditation examinations. The centres and candi-
dates who pass the assessment process successfully are entitled
with a diploma/certificate indicating training excellence and profi-
ciency, respectively, which will be endorsed and accredited by
the EHRA (see Figures 1 and 2). The first EHRA’s Accreditation
Figure 1 Accreditation certification title issued by EHRA for exams for Invasive Electrophysiology and for Implantable devices
professionals who are trained in implantable cardiac rhythm
were held in 2005 and the first EHRA’s Accreditation titles were
devices and who have passed a theoretical examination.
issued in 2006.5
Core curriculum for the heart rhythm specialist iii23

Trainee assessment

Requires thorough

experience in the
expertise and/or
A written report signed and stamped by the Training Programme

Very difficult
Director, as well as the Head of Service and/or Manager of the cor-
responding centre certifying that the applicant has completed full-

,30%
time training of at least 2 years in the said laboratory. This report

field
,4
5
should detail the activities undertaken, and the degree of compe-

average candidate passing the exam

tence and autonomy attained by the trainee, and allow verification

Requires special knowledge and/or

experience in the field that goes
that all the modalities of HR investigation and management modal-

beyond that expected from an

ities 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

Difficult

,50%
the trainee or the training supervisor. A normalized form for

Downloaded from europace.oxfordjournals.org at KU Leuven on October 4, 2010

these reports should be used for convenience.

Requires special knowledge in

candidate passing the exam

expected from an average
Procedural logbooks

the field that should be

The trainees should provide a continuous record (logbook) report
detailing their cardiac electrophysiological and HR implantable

Table 15 Average difficulty scale for questions used in a HR subspecialty accreditation examination
device training and experience, which must include the required
clinical procedures as the first and secondary operator during

Average
the training. The log book should contain a summary with the

60%

Can be answered by a ‘basic candidate (BC)’ (someone passing the exam with just the minimum requirements, i.e. 60%) in percent.
,2
number of procedures performed, the level of competence

3
achieved, and a list of the main procedures with the following data:

the field (is not necessarily common to the

majority of general cardiologists without
Requires more than basic knowledge in
1. Centre where the procedure was performed
2. Date of the procedure
3. Patient’s birth date and sex

special expertise in the field)

4. The patient’s clinical history or register numbers (where the
former is unavailable and if permitted by the national data pro-
tection law)
5. Diagnosis
6. Type of procedure (diagnostic study, ablation, PM, ICD, and CRT)
7. Result of the procedure (success or failure)
70%
Easy

8. Type of complications, if applicable.

,1
2

If different criteria lead to different grades, the highest grade should be used.

This log book will have an electronic format to facilitate data

Time to analyse elaborate figures or data by a ‘basic candidate’ in minutes.
Requires basic knowledge in the field

general cardiologists without special

(is also common to the majority of

input and importation from other computer applications. A data-

base will be available and will be used to ease the process of infor-
mation and requirement submission (internet-based). A printed
copy of the log book must be dated, signed, and stamped by the
expertise in the field)

Head of Service and/or Manager of the corresponding centre.

The candidates for accreditation by this method must attach a stan-
dard signed letter of authorization agreeing to facilitate and
Very easy

cooperate with an eventual audit of the procedures reported.

90%
,0.5

The EHRA reserves the right to make formal complaints or accu-

sations within a legal or professional ethics framework as con-

Knowledge requirements

sidered 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 implanta-
Grade

Timeb

ble devices, if it is considered convenient in terms of exam duration

BCa

or candidate participation promotion due to particular national

b
a

idiosyncrasies or other reasons. Minor aspects of the examinations

iii24 J.L. Merino et al.

may change from one edition to another, but they should essen- Assessment appeals
tially consist of a test with 100 –200 multiple-choice questions, A period for appeals will be opened after the candidates and the
with five possibilities being offered of which only one will be centres are notified of their accreditation application exam result
correct. These questions will include both academic knowledge and resolution. The candidate should address his/her appeal or
and the analysis of traces or practical clinical suppositions and complaint to the Chairperson of the Accreditation Committee.
decision-making. The question content is shown in the Syllabus.
The number of questions with the purely clinical cardiac electro-
physiological and implantable devices content will not be ,60%. Reaccreditation and revocation
The average difficulty grade of the exam should be balanced At its discretion, the EHRA is empowered to revoke accreditation
(between 2.5 and 3.5 according to a defined scale shown in if the accredited professional or centre was not qualified to receive
Table 15). The examinations will be compiled by an Accreditation accreditation at the time it was granted. Similarly, accreditation
Committee. may be revoked if it is proven that the accredited professional
The examination will use specially designed forms for the confi- or centre acts incompetently or in a professionally or ethically
dentiality and privacy of the participants, The Accreditation Com- unsatisfactory manner.
mittee will, at all times, maintain the integrity and confidentiality of The EHRA reserves the right to institute proceedings through all
the process and will be empowered to invalidate the examination legal and administrative means as deemed necessary in the case of
of any candidate if irregularities are detected. inappropriate use, whether intentional or not, of the denomination

Downloaded from europace.oxfordjournals.org at KU Leuven on October 4, 2010

‘EHRA Accredited’ and its derivatives.

Assessment of professionalism
Assessment of whether the trainee qualifies as a professional or Accreditation committee
not is important in the evaluation process of the trainee. The Composition
3608 assessment is a holistic assessment.6 Professionals gravitating The committee will be composed of 5 to 10 EHRA members (it is
and with whom the trainee is interacting are prompted by email to advisable that they are accredited), 1 of these being the chairper-
answer questions on the trainee. These questions relate to attitude son of the Committee and, therefore, necessarily a member of the
as well as professional aptitudes. Answers are then processed to EHRA Board. These members will be appointed by the EHRA
reveal the trainee’s areas of strength and areas for improvement. Board of Directors. Given that no EHRA members will be accre-
This method is largely implemented in commercial companies dited when the Accreditation System is initiated, the first Accred-
and it should be desirable to implement it in the future. Alterna- itation Committees will be formed by EHRA members with
tively to 3608 assessment, a simple questionnaire (on team work, recognized prestige and merit.
etc.) of 10 questions could be completed by several co-workers
(programme director, nurses, surgeons, other trainees, etc.). Functions
The functions of the Accreditation Committee are as follows:
† Announce and open the period for the call for applications for
Training centre assessment Accreditation from both professionals and training centres, as
The Accreditation Committee will announce the period for the well as the management of the same.
submission of accreditation centre applications. Accreditation can- † Co-ordinate the degree and diploma verification and audits to
didates, whether European or non-European, must submit a stan- evaluate the merits of those professionals and centres applying
dard form, a report on the centre’s activities detailing all the merits for accreditation, as well as participation in carrying out the
for patient care, research, and training, and a letter from the same when deemed necessary.
national society HR organizations supporting the quality of the † Prepare and compose the theoretical examination exercises;
training centre and the programme supervisor and the lack of maintain a question database for the composition of future
knowledge about inappropriate or unethical conduct. theoretical examinations.
The Accreditation Committee may organize audits or delegate † Co-ordinate and manage the theoretical accreditation examin-
them to the National Working Groups on HR management, ation results evaluation.
which would act as team of evaluators under the support and † Offer and attend any possible appeals from accreditation candi-
expertise of the Accreditation Committee. For this purpose, can- dates about the evaluation of the merits they present or the
didate centres for accreditation by this method must attach a stan- results of their theoretical accreditation examination.
dard signed letter of authorization agreeing to facilitate and † Submit ratification of accreditation of those candidates who are
cooperate with an eventual audit. The EHRA reserves the right considered suitable by virtue of the results obtained in the
to make formal complaints or accusations within a legal or pro- theoretical examination to the EHRA Board of Directors
fessional ethics framework as considered necessary in the case Committee.
of data falsification. † Maintain a register of those who are accredited together with
After evaluating the applications, checking the documentation, their merits and requisites accomplished.
and performing the corresponding audits, the Accreditation Com- † Maintain a register of activities and the activities of previous
mittee will notify candidates about the result of their application by Accreditation Committees.
letter. † Promote and support the organization of training courses.
Core curriculum for the heart rhythm specialist iii25

† Notify the EHRA Board of Directors of any changes in the Elections

accreditation system that are deemed necessary to adapt to Designation for committee members will be held every 2 years,
changes and evolution in HR management. following the elections for the EHRA Board of Directors. With
† Implement any changes that are deemed necessary to adapt the the objective of guaranteeing renewal and a degree of continuity,
accreditation system to changes and evolution in HR half of the members should be reelected every 2 years.
management.
† Co-ordinate this adaptation with those in other national or
European accrediting entities, and if considered appropriate,
Continuous medical education and
those of non-European international standing. maintaining competence
† Take steps to publicize the accreditation system so it becomes
Continuous medical education (CME) in cardiology subspecialities
known and can serve as a reference for third parties.
are important because knowledge and skills are continuously
† Keep the EHRA Board of Directors informed about the activities
developing and evolving. Continuous learning and practice are
of, the status of, and the changes in the accreditation system.
required to maintain standards and practice and because substan-
tial changes may occur in clinical practice or the health-care
Frequency of meetings
environment. Training seminars and international specialist confer-
The Accreditation Committee will hold ordinary meetings at least
ences must be attended (at least two per year). Courses offered in
twice a year. The Secretary to the Committee may call extraordi-

Downloaded from europace.oxfordjournals.org at KU Leuven on October 4, 2010

innovative techniques employed in specialized laboratories should
nary meetings at the request of the Chairman of the EHRA Board
be also attended. Continued practice may indicate 16 h per week
of Directors for matters of sufficient urgency or importance.
working in the subspecialty field. Continued learning may indicate
200 CME credits over a 5 year period in the field of HR
Attendance management.
Accreditation Committee meetings will always be held with a Therefore, accreditation as a HR specialist is time limited and
quorum equal to half the members plus one. 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
Dependence Committee, whenever a suitable electronic platform is available.
The Accreditation Committee will be appointed by and organically Reaccreditation requires submission and validation of evidence of
dependent on the EHRA Board of Directors. continued learning and practice within the subspecialty.

Author’s funding by private biomedical companies*

Author Consulting fees honoraria Speaker’s Bureau Ownership Research grants Fellowship support
partnership and other benefit
principal
.................................................................................................................................................................................
Jose L. Merino Magnetecs, Medtronic, St Jude Meda Pharma, Medtronic, None Magnetecs Boston Scientific,
Medical, Sanofi-Aventis St Jude Medical, Medtronic, St Jude
Sanofi-Aventis Medical
Fernando Arribas Sanofi-Aventis Boston Scientific, St Jude None None None
Medical
Giovanni Luca Botto None None None None None
Heikki Hukuri None Biotronik, Medtronic None Medtronic None
Lars I. Kraemer Medtronic, Sorin Group Biotronik, Boston None None None
Scientific, Medtronic,
Sorin Group, St Jude
Medical
Cecilia Linde Medtronic, St Jude Medical Medtronic, St Jude None Medtronic None
Medical
John M. Morgan None None None None None
Martin Schalij Boston Scientific Biotronik, Boston None Biotronik, Boston None
Scientific Scientific,
Medtronic, St Jude
Medical
Emmanuel None None None None None
Simantirakis

Continued
iii26 J.L. Merino et al.

Continued

*Funding received was not related to this study.

4. Kearney P, Oktay Ergene A, Escaned J, Flachskmpf F, Griebenow R, Kristesen S

References

Downloaded from europace.oxfordjournals.org at KU Leuven on October 4, 2010

et al. Education Committee of the European Society of Cardiology. Core
1. Brugada J, Vardas P, Wolpert C. The EHRA white book 2008: the current status of Curriculum for the General Cardiologist. Nice, France: European Society of Cardiology;
Cardiac Electrophysiology in ESC member countries. http://www.escardio.org/ 2006.
communities/EHRA/publications/Documents/ehra-white-book-2008.pdf (10 May 5. EHRA Accredited professionals in Cardiac Pacing and Electrophysiology. http://www.
2009, date last accessed).
escardio.org/communities/EHRA/accreditation/Pages/accredited-professionals-cp-ep.
2. Lopez-Sendon J, Mills P, Weber H, Michels R, Di MC, Filippatos GS et al. Rec-
aspx (10 May 2009, date last accessed).
ommendations on sub-speciality accreditation in cardiology: The Coordination
6. Whitehouse A, Walzman M, Wall D. Pilot study of 3608 assessment of personal
Task Force on Sub-speciality Accreditation of the European Board for the Special-
skills to inform record of in-training assessments for senior house officers. Hosp
ity of Cardiology. Eur Heart J 2007;28:2163 –71.
Med 2002;63:172 –5.
3. American Board of Internal Medicine: Exam Administration History. http://www
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