This Advanced Training Statement addresses the core competencies required of interventional cardiologists, including competencies related to coronary, peripheral vascular, and structural heart interventions. The competencies for coronary interventions in adults serve as the foundation for cardiologists who wish to pursue training in peripheral vascular or structural heart interventions. This statement identifies select competencies for interventional cardiologists who choose to focus their careers on peripheral vascular or structural heart interventions that some advanced trainees may acquire either during formal fellowship training or through subsequent training experiences. This document provides examples of appropriate measures for assessing competence in the context of training.
All authors: Theodore A. Bass, MD, MSCAI, Chair; J. Dawn Abbott, MD, FSCAI, Vice Chair; Ehtisham Mahmud, MD, MSCAI, Vice Chair; Sahil A. Parikh, MD, FSCAI, Vice Chair; Jamil Aboulhosn, MD, FSCAI; Mahi L. Ashwath, MD, MBA; Bryan Baranowski, MD; Lisa Bergersen, MD, MPH, FSCAI; Hannah I. Chaudry, MD; Megan Coylewright, MD, MPH, FSCAI; Ali E. Denktas, MD, FSCAI; Kamal Gupta, MD; J. Antonio Gutierrez, MD, MHS; Jonathan Haft, MD; Beau M. Hawkins, MD, FSCAI; Howard C. Herrmann, MD, MSCAI; Navin K. Kapur, MD, FSCAI; Sena Kilic, MD; John Lesser, MD; Huie Lin, MD, PhD, FSCAI; Rodrigo Mendirichaga, MD; Vuyisile T. Nkomo, MD, MPH; Linda G. Park, PhD, FNP-BC, MS; Dawn R. Phoubandith, MSW; Nishath Quader, MD; Michael W. Rich, MD; Kenneth Rosenfield, MD, MHCDS, MSCAI; Saher S. Sabri, MD; Murray L. Shames, MD; Stanton K. Shernan, MD; Kimberly A. Skelding, MD, FSCAI; Jacqueline Tamis-Holland, MD; Vinod H. Thourani, MD; Jennifer A. Tremmel, MD, MS, FSCAI; Seth Uretsky, MD; Jessica Wageman, MPAS, PA-C; Frederick Welt, MD; Brian K. Whisenant, MD, FSCAI; Christopher J. White, MD, MACC, MSCAI; and Celina M. Yong, MD, MBA, MSc, FSCAI.
The American College of Cardiology (ACC), the American Heart Association (AHA), the American College of Chest Physicians (ACCP), and the Heart Rhythm Society (HRS) have issued an updated guideline for preventing and optimally managing atrial fibrillation (AF).
The 2023 ACC/AHA/ACCP/HRS Guideline for Diagnosis and Management of Atrial Fibrillation was published online today in the Journal of the American College of Cardiology and Circulation.
"The new guideline has important changes," including a new way to classify AF, Jose Joglar, MD, professor of cardiac electrophysiology at UT Southwestern Medical Center in Dallas, Texas, and chair of the writing committee, told theheart.org | Medscape Cardiology.
The previous classification was largely based only on arrhythmia duration and tended to emphasize specific therapeutic interventions rather than a more holistic and multidisciplinary management approach, Joglar explained.
The new proposed classification, using four stages, recognizes AF as a disease continuum that requires a variety of strategies at different stages, from prevention, lifestyle and risk factor modification, screening, and therapy.
- Stage 1: At risk for AF due to the presence of risk factors
- Stage 2: Pre-AF, with evidence of structural or electrical findings predisposing to AF
- Stage 3: AF, including paroxysmal (3A), persistent (3B), long-standing persistent (3C), successful AF ablation (3D)
- Stage 4: Permanent AF
The updated guideline recognizes lifestyle and risk factor modification as a "pillar" of AF management and offers "more prescriptive" recommendations, including management of obesity, weight loss, physical activity, smoking cessation, alcohol moderation, hypertension, and other comorbidities.
"We should not only be telling patients they need to be healthy, which doesn't mean much to a patient, we need to tell them precisely what they need to do. For example, how much exercise to do or how much weight to lose to have a benefit," Joglar told theheart.org | Medscape Cardiology.
The good news for many people, he noted, is that coffee, which has had a "bad reputation," is okay, as the latest data show it doesn't seem to exacerbate AF.
The new guideline continues to endorse use of the CHA2DS2-VASc score as the predictor of choice to determine the risk of stroke, but it also allows for flexibility to use other calculators when uncertainty exists or when other risk factors, such as kidney disease, need to be included.
With the emergence of "new and consistent" evidence, the guideline also emphasizes the importance of early and continued management of patients with AF with a focus on maintaining sinus rhythm and minimizing AF burden.
Catheter ablation of AF is given a Class 1 indication as first-line therapy in selected patients, including those with heart failure with reduced ejection fraction.
That's based on recent randomized studies that have shown catheter ablation to be "superior to pharmacological therapy" for rhythm control in appropriately selected patients, Joglar told theheart.org | Medscape Cardiology.
"There's no need to try pharmacological therapies after a discussion between the patient and doctor and they decide that they want to proceed with the most effective intervention," he added.
The new guideline also upgrades the class of recommendation for left atrial appendage occlusion devices to 2a, compared with the 2019 AF Focused Update, for use of these devices in patients with long-term contraindications to anticoagulation.
It also provides updated recommendations for AF detected via implantable devices and wearables as well as recommendations for patients with AF identified during medical illness or surgery.
Development of the guideline had no commercial funding. Disclosures for the writing group are available with the original articles.