Guidelines set flexible framework to help interventional cardiology trainees meet career “benchmarks”

Theodore Bass (University of Florida, Jacksonville, USA), chair of the joint committee tasked with producing the ACC and AHA joint training guidelines tells Cardiovascular News about the process of drafting of the document, its intended scope, and the current state of training for interventional cardiologists.

“WE WANT TO CREATE A roadmap for training to produce not only cognitively but also procedurally competent interventional cardiologists, regardless of where they trained”, outlined Bass. Aware that the expanding speciality of interventional cardiology has bled into adjacent fields such as peripheral, congenital heart and structural interventions, Bass underlines that the presiding importance of the guidelines is to ensure trainees are “well-trained”, to enable “comfortable, portable and individual cardiology”.

The document elects three main areas, namely coronary, peripheral, and structural heart interventions. In brief, their proposed training pathway to gain the required amount of experience includes a three-year general cardiovascular disease fellowship, a year of accredited interventional cardiology fellowship, and a final option to participate in post-fellowship training, based on the individual’s desired career trajectory.

The writing committee emphasises that Level III training aims to provide trainees with a well-rounded, competency-based education, including didactic instruction, clinical experience in the diagnosis and hands-on care of patients.

The writing committee also recommends a minimum of 250 interventional cardiology procedures. Of the 250 procedures, 200 should be coronary, with the remaining 50 specialised in coronary, peripheral or structural interventions.

“It is an issue—how can you designate competency in the surgical or procedural field? It centres around your exposure and experiences, however it is not a one-size-fits-all situation”, Bass explains. He states that some trainees may need more procedural experience, noting that the figures themselves career goals. Adjunctive procedures related to physiologic assessment and intracoronary imaging are also required (25 of each). These minimum numbers are meant to provide trainees with exposure to a variety and spectrum of complexity of clinical case material and give supervising faculty sufficient opportunity to evaluate trainees’ competency.

Trainees must also acquire experience working as part of a multidisciplinary team to provide a holistic approach to patient care. The document also highlights the importance of cardiovascular health equity, mentorship and lifelong learning.

The “2023 ACC/AHA/SCAI Advanced Training Statement on Interventional Cardiology (Coronary, Peripheral Vascular, and Structural Heart Interventions)” is published simultaneously in the Journal of the American College of Cardiology, Circulation: Cardiovascular Interventions, and the Journal of the Society of Cardiovascular Angiography and Interventions were meant to provide programmatic, procedural training guidance following in-depth discussions involving a diverse group of interventional cardiologists, interventional cardiology training directors and trainees and representatives from various professional societies and specialties involved in the cardiovascular field: “One number or another number might be uncomfortable for some, but the numbers are a means of guidance. I am very comfortable that we have come out with some thoughtful and very reasonable recommendations.”

The statement was developed in collaboration with and endorsed by the American Association for Thoracic Surgery, the American Society of Echocardiography, the Heart Failure Society of America, the Heart Rhythm Society, the Society of Cardiovascular Anesthesiologists, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, the Society of Thoracic Surgeons and the Society for Vascular Medicine.

Taking an almost “holistic approach” to patient care, the guidelines require trainees to work within a multidisciplinary team and emphasises the importance of cardiovascular health equity, mentorship and lifelong learning.

Echoing this, Bass reiterates that training is a “lifelong process”, observing that, despite entering the latestages of his interventional career, he is “learning things all the time”, including patient-facing communication and interpersonal skills.

Bass makes clear that pastoral skills and system-based practices are also at the core of the proposed guidelines, making for a “better professional, no matter what field they enter”. He accentuates that for patients that perhaps speak another language, ensuring they “know what their choices are, and that they know they are in charge of their healthcare, so that they feel comfortable and not forced into agreement—we are not selling cars, we are here to educate them on very important aspects of their healthcare”.

Returning to the foundations of the guidelines, Bass reiterates the potential this roadmap has in providing a flexible framework to help trainees reach “benchmarks” and set “objectives and goals” in their career. He adds that interventional cardiology is a heavily subscribed specialty today, which has included an increasing number of female professionals entering the field. Overall, Bass concludes that the field is heading in the “right direction”, and in providing these guidelines they hope to improve the training pathway to produce well-rounded, multidisciplinary interventional cardiologists.

A region-wide study in more than 50,000 patients with atrial fibrillation (AF) has found reduced risks of stroke and transient ischaemic attack in those who started statins within a year of diagnosis compared with those who did not. The findings were presented at the annual congress of the European Heart Rhythm Association (EHRA 2023, 16–18 April, Barcelona, Spain).

“Our study indicates that taking statins for many years was even more protective against stroke than short-term use,” said study author Jiayi Huang (University of Hong Kong, Hong Kong).

AF is the most common heart rhythm disorder, affecting more than 40 million people worldwide. Patients with the condition have a five times greater risk of stroke than their peers. Anticoagulant medication is recommended to prevent strokes in those with AF but does not completely eliminate risk. Statin therapy is widely prescribed to lower blood cholesterol and reduce the likelihood of heart attack and stroke. However, the benefit of statins for stroke prevention in patients with AF has been unclear.

This study evaluated the association between statin use and the incidence of stroke and transient ischaemic attack in patients with AF. The researchers used the Hong Kong Clinical Data Analysis and Reporting System to identify all patients with a new diagnosis of AF between 2010 and 2018. Participants were divided into two groups: statin users and non-users. Users had received statins for at least 90 consecutive days during the year after being diagnosed with atrial fibrillation.

The primary outcomes were the combined endpoint of ischaemic stroke or systemic embolism; haemorrhagic stroke; and transient ischaemic attack. Patients were followed until the occurrence of the primary outcomes, death or the end of the study on 31 October 2022.

A total of 51,472 patients with a new diagnosis of AF were included, of which 11,866 were classified as statin users and 39,606 were non-users. The median age of participants was 75 years and 48% were women. During a median follow-up of five years, statin users had a significantly lower risk of all primary outcomes compared to non-users. Statin use was associated with a 17% reduced risk of ischaemic stroke or systemic embolism (hazard ratio [HR] 0.83; 95% confidence interval [CI] 0.78–0.89), a 7% reduced risk of haemorrhagic stroke (HR 0.93; 95% CI 0.89–