Program Director Survey Shows Variation in CV Imaging Training

A study based on a survey of 50 directors of advanced cardiovascular imaging (ACVI) training programs in the United States and Canada suggests that cardiology imaging fellows are receiving nonstandardized training.

Part of the reason is that CV imaging includes four modalities, and it is not accredited by the Accreditation Council for Graduate Medical Education (ACGME), researchers say.

"We're training a lot of folks to do advanced imaging, and we're not doing it in an accredited fashion or in a standardized fashion," Todd C. Villines, MD, University of Virginia School of Medicine in Charlottesville, the senior study author, told theheart.org | Medscape Cardiology in an interview.

"This tells us that the status quo has to change," he said.

The work will be presented as a poster at the virtual American College of Cardiology 2020 Scientific Session (ACC.20)/World Congress of Cardiology and was published online March 16 in JACC: Cardiovascular Imaging.

"It is time for the ACVI community to work together and identify collaborative solutions for this unique CV subspecialty," the authors urge.

The survey showed that most programs (94%) offered cardiology fellows advanced training in more than one of the four cardiology imaging modalities — cardiac computed tomography (CT), cardiac magnetic resonance imaging (MRI), echocardiography, and nuclear imaging — but the programs varied in length (1 or 2 years) and number of modalities that were covered.

There is no standardized training, largely because unlike the cardiology subspecialties of interventional cardiology, advanced heart failure and transplantation, and clinical cardiac electrophysiology, ACVI is not an ACGME-accredited subspecialty, lead author Gaby Weissman, MD, Georgetown University, Washington, DC, and colleagues suggest.

Four different imaging board exams are offered (one for each imaging modality), although not everyone needs to take them all.

Joint Annual Meeting for Imaging Subspecialties?

"The subspecialties that are recognized by ACGME can be funded and therefore attract the best candidates," Mario J. Garcia, MD, chief of cardiology, professor of medicine and radiology, and co-director of the Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York, who was not involved in the study, told theheart.org | Medscape Cardiology.

Because the different skills that need to be acquired to master all of these imaging modalities are almost impossible to acquire in 1 year, he said, the programs must focus on one or two areas at most, creating lack of uniformity and standardization in training.

Moreover, he said, "All the disciplines are represented by societies that operate in silos, forcing individuals to choose which meetings to attend every year and which societies to join as members."

"In my opinion," Garcia said, "the four societies that represent the imaging subspecialties"—the American Society of Nuclear Cardiology (ASNC), the Society for Cardiovascular Angiography and Interventions (SCAI), the Society of Atherosclerosis Imaging and Prevention (SAIP), and the Society of Cardiovascular Computed Tomography (SCCT)—"should join to conduct their annual meetings in the same venue and at the same time, create a common certification pathway/exam, and offer a joint membership."

According to Garcia, that has been a successful model in Europe and will facilitate ACGME recognition.

"It will be helpful to have CV imaging recognized as an ACGME-accredited subspecialty," said Ron Blankstein, MD, co-director of a 2-year, multimodality noninvasive cardiovascular imaging training program, director of cardiac computed tomography, and a preventive cardiology specialist at Brigham and Women's Hospital, Boston, Massachusetts.

Echocardiography and nuclear imaging training have been an integral part of training in cardiology, Blankstein, who participated in the survey, explained to theheart.org | Medscape Cardiology in an email.

But more recently, it is recognized that all cardiologists need to also train in cardiac CT and cardiac MRI, he continued, to understand the strengths and limitations of all of these tests so they know when to order them and how to use the test results in patient management.

According to Blankstein, who is also an associate professor in medicine and radiology at Harvard Medical School in Boston, "CV imaging is an integral part of everything we do in cardiology," including prevention, heart failure, treatment of coronary artery disease, structural heart disease, electrophysiology, or congenital heart disease, so having expertise in advanced imaging is a must.

Historically, cardiologists were trained to do echocardiography and nuclear single-photon emission CT (SPECT) imaging during their general cardiology fellowship, typically a 3-year training program, Villines said, and cardiologists would get these skills during that 3 years and go on to practice.

"Now over the last 10 to 15 years, this new specialty has emerged—advanced cardiovascular imaging—and it's really becoming a distinct subspecialty in cardiology," he added.

Snapshot of Current ACVI Training

To examine the current state of ACVI training, the researchers sent surveys to 66 ACVI training programs (64 US, 2 Canadian) in March and April 2019, which they found from the ACC advanced imaging program database and from contacting leaders in imaging societies.

They received replies from 50 programs (49 US, 1 Canadian), a 76% response rate.

The 151 ACVI trainees in these programs are similar to the number of trainees in interventional cardiology (339), clinical cardiac electrophysiology (259), and advanced heart failure and transplantation (105) in the same year.

Slightly more than half of the ACVI trainees (60%) were men.

Programs were small (a median of one trainee), so "it creates challenges for people to find these opportunities and to apply," said Villines. "When you get in, many times one program does not look anything like another program."

Three-quarters of the programs (74%) relied on institutional or departmental funding, he noted, "which is very different from other specialties in cardiology and in medicine, where we have external funding through Medicare or other sources."

Program directors were almost all cardiologists (94%), and for most, less than 10% of their working time was "protected" for administering the programs.

The programs offered training in cardiac MRI (94%), cardiac CT (84%), echocardiography (74%), and nuclear imaging (48%).

Most programs (70%) were 1 year long, and most required training in cardiac MRI, cardiac CT, or echocardiography, whereas only 20% required training in nuclear imaging.

"There's very little time to train in cardiac MI and cardiac CT in general cardiology," Villines noted.

Most nuclear imaging training programs (71%) offered training in positron emission tomography (PET), and most echocardiography programs offered advanced structural/interventional training.

Only 48% of the program directors said that imaging certification exams were important, 34% had a neutral opinion, and 16% said they were not important.

"I am intrigued by the large number of respondents who see no value in having a certification exam," said Garcia.

Close to half of the program directors (48%) favored a modular exam, 28% favored an exam for each imaging modality (the current system), 14% favored a single integrated multimodality exam, and 6% favored no certification exams.

"Making trainees take four to six board exams is not ideal, and I think we need to move to a multimodality assessment model that mirrors how advanced imagers practice," Villines said.

Weissman directs an academic cardiovascular imaging corelab with institutional contracts with Abbott, Ancora Heart, Boston Scientific, LivaNova, and Medtronic. The other authors have no relevant financial disclosures.

American College of Cardiology 2020 Scientific Session (ACC.20)/World Congress of Cardiology.

JACC Cardiovasc Imaging. Published online March 16, 2020. Abstract

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