Proposal for a Core Curriculum for a European Sports Cardiology Qualification

Transcription

1 Proposal for a Core Curriculum for a European Sports Cardiology Qualification Hein Heidbuchel 1, Michael Papadakis 2, Nicole Panhuyzen-Goedkoop 3, François Carré 4, Dorian Dugmore 5, Klaus-Peter Melwig 6, Hanne K Rasmusen 7, Erik E Solberg 8, Mats Borjesson 9, Domenico Corrado 10, Antonio Pelliccia 11, Sanjay Sharma 12 on behalf of the Section on Sports Cardiology of the European Association for Cardiovascular Prevention and Rehabilitation (EACPR) of the European Society of Cardiology (ESC) 1. Department of Cardiovascular Medicine, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium 2. Cardiac and Vascular Division, St George s University of London, London, UK 3. Radboud University Hospital Nijmegen MC & Sports Medical Center, Papendal, Arnhem, The Netherlands 4. Department of functional explorations- Pontchaillou Hospiital-Rennes 1 University INSERM U 642-Rennes, France 5. Wellness Medical Center, Stockport, UK 6. Heart Center NRW, University Hospital, Bad Oeynhausen, Germany 7. Department of Cardiology, Bisbebjerg University Hospital, Copenhagen, Denmark 8. Department of Medicine, Diakonhjemmet Hospital, Oslo, Norway 9. Department of Acute and Cardiovascular Medicine, Sahlgrenska University Hospital, Goteborg, Sweden 10. Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy 11. Institute for Sports Medicine and Science, Rome, Italy Short title: Core curriculum for the sports cardiologist Address for correspondence: Hein Heidbuchel, M.D., Ph.D. Cardiology - Electrophysiology University Hospital Gasthuisberg Herestraat 49 B-3000 Leuven Belgium Europe Phone: Fax: Hein.Heidbuchel@uz.kuleuven.ac.be Word count: 4631 words (excluding abstract, tables, and references)

2 Section Sports Cardiology Core curriculum for the sports cardiologist page 1 Abstract Sports cardiology is a new and rapidly evolving subspecialty. It aims to elucidate the cardiovascular effects of regular exercise and delineate its benefits and risks, so that safe guidance can be provided to all individuals engaging to sports activity in order to attain the maximum potential benefit at the lowest possible risk. The European Society of Cardiology (ESC) advocates systematic pre-participation cardiovascular screening in an effort to identify competitive athletes at risk of exercise-related cardiovascular events and sudden cardiac death (SCD). However, the implementation of pre-participation screening is hindered because of lack of structured training and as a result lack of sufficient expertise in the field of Sports Cardiology. In 2008 the European Society of Cardiology published a core curriculum for the general cardiologist, in which Sports Cardiology was incorporated within the topic Rehabilitation and Exercise Physiology. However, the exponential rise in knowledge and the growing demand for expertise in the field of Sports Cardiology dictates the need to systematically structure the knowledge base of Sports Cardiology into a detailed curriculum. We envisage that the curriculum would facilitate more uniform training and guideline implementation throughout Europe and safeguard that evaluation and guidance of competitive athletes or individuals who wish to engage in leisure-time sports activities is performed by physicians with expertise in the field. The current manuscript provides a comprehensive curriculum for Sports Cardiology, which may serve as a framework upon which universities, national and international health authorities will develop the training, evaluation and accreditation in Sports Cardiology. Key Words Sports cardiology - Education - Sports medicine - Curriculum - Certification

3 Section Sports Cardiology Core curriculum for the sports cardiologist page 2 Introduction Scope Sports cardiology is a new and rapidly evolving subspecialty. It derives its inception from the ancient awe for athletic achievements that excel human nature, the recognition that habitual exercise is an antidote to the cardiovascular risks of the modern diet and lifestyle, but also from the acknowledgement of the inherent risks of athletic excellence in predisposed individuals (Figure 1). Sports cardiology s role today is as important as ever, being an integral part in the society s attempt to combat the growing obesity pandemic, prevent cardiovascular disease and create a healthier population. Sports cardiology aims to elucidate the cardiovascular effects of regular exercise and delineate its benefits and risks, so that safe guidance can be provided to all individuals engaging in sports activity in order to attain the maximum potential benefit at the lowest possible risk. The section of Sports Cardiology, part of the European Association for Cardiovascular Prevention and Rehabilitation (EACPR) of the European Society of Cardiology (ESC), advocates systematic pre-participation cardiovascular screening in an effort to identify at an early stage athletes at risk of exercise-related cardiovascular events and sudden cardiac death (SCD). 1 Main sporting bodies including FIFA, UEFA and the IOC have endorsed the European recommendations. 2, 3 However, the implementation of pre-participation screening remains fragmented and there is lack of consensus relating to the exact methodology. Most European countries do not offer state-funded pre-participation screening and some object to such an endeavour, amid fears of a large number of false positive results leading to unnecessary investigations, anxiety and potential false diagnoses and disqualification from sport. Such concerns are fuelled by observations that regular exercise is associated with ECG manifestations of physiological cardiovascular adaptations that occasionally overlap with phenotypes exhibited in cardiac disease, making differentiation between physiology and pathology challenging (Figure 2). Furthermore, there is a paucity of structured training programs to develop individuals with sufficient expertise in the field of Sports Cardiology. Since 2005, the Section on Sports Cardiology has contributed to the endeavour for a healthier population, by publishing several recommendations and consensus documents on pre-participation screening of young (<35 years old) 1 and senior athletes, 4 the interpretation of electrocardiographic and imaging findings in athletes, 5 the cardiovascular effects of doping, 6 as well as the eligibility for leisure-time or competitive sports in athletes with cardiovascular disease or patients who wish to engage in physical activity Additionally, the group has published recommendations regarding the cardiovascular safety of both athletes and spectators in mass gathering events in sports arenas, outlining minimum standards and potential challenges, in an attempt to ensure prompt cardiopulmonary

4 Section Sports Cardiology Core curriculum for the sports cardiologist page 3 resuscitation and access to an automated external defibrillator, to improve survival from sudden cardiac arrest at sporting events. 11 Moreover, every year the Section of Sports Cardiology organises/contributes to numerous national and international scientific conferences and forums, educating physicians. Finally, the group is in the process of creating an interactive website ( to provide up to date educational material and create a platform for the exchange of ideas and advancement of knowledge in the field of Sports Cardiology. In 2008 the European Society of Cardiology published a core curriculum for the general cardiologist, in which Sports Cardiology was incorporated within the topic Rehabilitation and Exercise Physiology. 12 Also some ESC Associations, like the European Heart Rhythm Association (EHRA) have published curricula for subspecialists. 13 The exponential rise in knowledge and the growing demand for expertise in the field of Sports Cardiology dictates also the need to systematically structure the knowledge base of Sports Cardiology into a detailed curriculum with a comprehensive list of the relevant topics. The curriculum should outline all essential knowledge, skills, and aptitudes required of physicians, to facilitate more uniform training and guideline implementation throughout Europe and safeguard the cardiovascular evaluation and guidance of competitive athletes or individuals who wish to engage in leisure-time sports activities. The current manuscript provides a comprehensive curriculum for Sports Cardiology. This curriculum may serve as a framework upon which universities, national and international health authorities will develop training programs, evaluations and accreditation in Sports Cardiology (Figure 3). Coordination at European level is essential to prevent duplication of efforts and ensure more uniform health services across borders for professionals, patients and athletes. The ESC, the EACPR, and the Section on Sports Cardiology The European Society of Cardiology (ESC) is a private, non-profit scientific organization dedicated to improving the quality of life of the European population by reducing the impact of cardiovascular disease. It aims to foster the development of cardiology, to promote scientific research across Europe, encourage personal contacts, and to establish standards of training for cardiologists and those working in the field of cardiovascular disease. The ESC does not receive public funds and is neither legislative nor authoritative. The society is comprised of both European and non-european cardiologists and other professionals related to cardiovascular diseases. The chairman and the board of directors are elected biennially.

5 Section Sports Cardiology Core curriculum for the sports cardiologist page 4 The European Association for Cardiovascular Prevention and Rehabilitation (EACPR) is a registered branch of the ESC. The goals of the EACPR are to promote excellence in research, clinical practice and educational policies in cardiovascular prevention and rehabilitation in Europe, as defined in its statutes. The EACPR maintains the links and cohesion with the entire ESC society, while allowing a more specific and fruitful development of its particular area of expertise. The Section on Sports Cardiology is one of the four constituent sections of the EACPR. Its primary objective is to promote safe participation in sports, by prevention of cardiovascular events and in particular sudden cardiac death in athletes, through education and research. The section supports and coordinates ongoing research at European and cross-continent level in several areas including: safety for athletes and public in sporting arenas and health fitness facilities; safety of sports participation in patients with cardiovascular disease (patients with implantable cardioverter defibrillator, myocarditis, valve disease); and optimising screening approaches for patients wishing to engage in sports Definitions and glossary Accreditation Accreditation is a process resulting in a diploma indicating proficiency. It signifies granting credit or recognition by national and international authorities. Its objective is to guarantee quality of specialist training and patient care. Certification Certification is not equivalent to accreditation. It involves passing an assessment of knowledge, which is only part of an accreditation process. Assessments of knowledge demonstrate objective competency in the theory within a field. Curriculum A curriculum is a formal education plan for a training programme that intends to establish specific learning outcomes. Syllabus A syllabus is a listing of subject matters that are covered in a training programme. Logbook A logbook is a record of the trainee s practical experience.

6 Section Sports Cardiology Core curriculum for the sports cardiologist page 5 General learning objectives of the Core Curriculum By setting general learning objectives, the core curriculum aims to establish a skill set of mandatory competences required of the trainee prior to completion of the training period. Although sports cardiology is not considered a separate subspecialty in most countries, a sports cardiology specialist is a cardiologist or sports physician with specific knowledge, training, skills and attitudes in cardiology, preventive medicine, and athlete s physiology. He/she should be able to perform qualified pre-participation cardiovascular evaluation of athletes, and to guide safe participation in exercise or competitive sports in patients with a recognized cardiovascular disorder. A sports cardiologist should also be able to educate other health care workers and patients on these topics. Ideally, the sports cardiologist should have some personal research experience in the field, or at least have become acquainted with relevant research topics through literature review. The general learning objectives of a trainee in sports cardiology are: 1. To understand the principles of exercise physiology and the acute and chronic changes that occur in the structure and function of the cardiovascular system and its regulation under the influence of exercise. The impact of age, gender, ethnicity and sporting discipline on cardiovascular adaptation should be appreciated. 2. To enhance the knowledge of sports participants and the general public on the value of sports activities and physical exercise in reducing cardiovascular risk factors and optimizing health. 3. To conduct cardiovascular pre-participation screening in order to prevent acute cardiovascular events and potential worsening of cardiovascular disease in athletes and to appreciate the ethical and legal aspects of screening. 4. To be familiar with the specificity of resting and exercise findings in athlete s heart. 5. To conduct appropriate investigations, risk stratification and management of athletes with cardiac disease through a multi-disciplinary approach inviting other specialists, coaches and trainers. 6. To be able to perform cardiac rehabilitation in athletes aiming at return-to-play and to monitor safe resumption of physical/sport activities. 7. To be able to carry out basic and advanced cardiac life support. 8. To manage and develop safety procedures in sports arenas, athletic fields, schools. 9. To appreciate the cardiovascular effects of substance abuse/doping.

7 Section Sports Cardiology Core curriculum for the sports cardiologist page 6 To reach these learning objectives and to become competent in the management of athletes, the trainee requires knowledge, skills, and the appropriate behaviours and attitudes, which are detailed below. The Core Syllabus The sports cardiology syllabus is a comprehensive index of existing knowledge in the field. It must be recognized however, that the syllabus should be considered as a summary guide rather than a detailed account of all possible aspects related to the field of sports cardiology. This is of particular relevance when one considers that sports cardiology is a rapidly evolving field with an expanding knowledge base and for formal aspects one should consider all data and information that has been published in peer-reviewed journals. Nevertheless, a pragmatic, summarized syllabus is of practical interest and is presented in this section. The syllabus is divided in ten sections, to facilitate programming of courses, allocation of credits during evaluation, and organisation of educational material in general. Section 1: Anatomy, physiology and health benefits 1.1. Types of sports Classification of sports: endurance vs. strength (dynamic vs. isometric; aerobic vs. anaerobic) Principles of training: aerobic vs. anaerobic training and training regimens 1.2. Cellular pathways and biomechanical pathways of energy production 1.3. Cardiovascular acute effects of exercise in healthy sedentary and trained people Blood pressure response during exercise Augmentation of cardiac output and oxygen consumption Age, gender and ethnic differences Exercise in extreme environmental conditions: heat, cold, altitude, diving 1.4. Long-term adaptation to exercise: athlete s heart Morphologic (anatomy) Functional: stroke volume, heart rate and cardiac output; oxygen transport and consumption Effect of age, gender, ethnicity, genetics and sporting discipline 1.5. Exercise and population health Benefits in reducing cardiovascular mortality in the general population Mechanisms for benefit of exercise: impact on risk factors Relation with fitness level and exercise level. Definition of an athlete

8 Section Sports Cardiology Core curriculum for the sports cardiologist page Exercise prescription Section 2: Cardiac evaluation in sports cardiology 2.1. Resting 12-lead ECG QT-correction using formulae or QT/RR slope regression Left ventricular hypertrophy criteria in athletes vs. control Physiological vs. non-physiological ECG changes in athletes common ECG patterns of the athlete s heart (with focus on different early repolarisation patterns) overlap ECG patterns (T-wave patterns; ST segment patterns; q waves) physiological vs. non-physiological arrhythmias (supraventricular; ventricular; heart blocks) Physiology of ECG patterns in athletes: autonomic nervous system influences, hypertrophy, intrinsic alterations Effect of age, gender, ethnicity and sports discipline 2.2. Exercise test Protocols Evaluation of ischemia, blood pressure and QT-interval Cardio-pulmonary fitness assessment and recommendations 2.3. Arrhythmia registration Ambulatory ECG (Holter, event recorders) Interpret results of implantable loop recorders 2.4. Other electrophysiological evaluations Signal average ECG Class-1 anti-arrhythmic drug provocation test Electrophysiological study 2.5. Imaging of the athlete s heart: anatomical and functional Echocardiogram Magnetic resonance imaging (MRI) Other: indications for functional imaging, coronary computed tomography (CT), coronary angiography 2.6. Principle and effects of detraining 2.7. Familial evaluation (first degree relatives)

9 Section Sports Cardiology Core curriculum for the sports cardiologist page Genotyping Section 3: Sudden death in sports 3.1. Epidemiology Prevalence Demographics: gender, ethnicity, sporting discipline, geographical differences Relation to age Diurnal variation 3.2. Causes Cardiac causes hereditary (hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, Marfan s syndrome, long and short QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia) acquired (atherosclerotic heart disease, coronary artery anomalies, myocarditis, Wolf-Parkinson-White syndrome, commotio cordis, aortic rupture, drug abuse, electrolyte disturbances, sarcoidosis) Non-cardiac causes hyperpyrexia, rhabdomyolysis, sickle cell anaemia, asthma, extreme environmental conditions (heat, cold, altitude) 3.3. Risk factors Section 4: Prevention of sudden death by screening 4.1. Cardiovascular screening of young athletes (12-14 to 35 years) Modalities Timing Type of athletes Components of recommended screening history (personal and family history) physical examination resting 12-lead ECG 4.2. Considerations concerning the use of the resting ECG in athletes Sensitivity

10 Section Sports Cardiology Core curriculum for the sports cardiologist page Specificity Efficacy Cost-effectiveness 4.3. Indications for exercise ECG and echocardiography in screening 4.4. Different perspectives on screening European perspective (ESC) FIFA, UEFA International Olympic Committee (IOC) American perspective 4.5. Education of athletes, coaches, teams and governing bodies 4.6. Cardiovascular screening of master athletes Assessment of competitive master athletes Assessment of leisure-time master athletes Assessment of referees 4.7. Cardiovascular screening of very young athletes (< 14 years) Section 5: Diagnostic conundrums in sports cardiology 5.1. Hypertrophic cardiomyopathy vs. athlete s heart 5.2. Arrhythmogenic right ventricular cardiomyopathy vs. athlete s heart 5.3. Dilated cardiomyopathy vs. athlete s heart 5.4. Long QT syndrome vs. athlete s heart 5.5. Brugada syndrome vs. athlete s heart 5.6. Physiologic vs. pathologic AV conduction disturbances Section 6: Sports eligibility with cardiac abnormalities 6.1. Sports eligibility with morphological cardiac abnormalities Hypertrophic cardiomyopathy and non-compaction Dilated cardiomyopathy and myocarditis Arrhythmogenic (right) ventricular cardiomyopathy (ARVC) Hypertension Valvular disease Congenital abnormalities Pericarditis - Myocarditis

11 Section Sports Cardiology Core curriculum for the sports cardiologist page Ischemic heart disease (symptomatic, silent, post-cabg or PCI) 6.2. Sports eligibility with arrhythmogenic cardiac abnormalities Pre-excitation syndromes and re-entrant arrhythmias Atrial fibrillation, atrial flutter, chaotic atrial rhythm Ventricular ectopic beats and ventricular tachycardia Channelopathies Conduction disorders and pacemaker therapy Implantable Cardioverter Defibrillator (ICD) Post commotio cordis Section 7: Screening and eligibility for sports: ethical and legal considerations 7.1. Ethical aspects Ethical aspects of screening Phenotypic evaluation Genotypic evaluation Psychological impact of screening (breaking bad news) Ethical aspects of disqualification from competitive sports participation (consideration of psychological, physical, social and financial impact) Ethical aspects of declining screening The athlete s right to refuse screening The team/federation that does not provide screening 7.2. Legal aspects Legal aspects of screening Legal aspects of disqualification for competitive sports participation Section 8: Cardiac rehabilitation and safe participation to sports 8.1. Cardiac rehabilitation in patients with cardiac abnormalities 8.2. Resuscitation on the field Basic and Advanced life support Automatic External Defibrillators (AED) Section 9: Cardiac safety at sports facilities 9.1. Cardiac safety at sports arenas

12 Section Sports Cardiology Core curriculum for the sports cardiologist page Current status Data on emergency response, including on-site defibrillation Recommendations for arena medical action plans 9.2. Cardiac safety at fitness/health facilities 9.3. Special considerations concerning outdoor races 9.4. Recommendations for medical action plans at schools, colleges Section 10: Cardiovascular effects of substance abuse / doping Effect of different pharmaceutical agents on exercise performance Physiological effects Psychological effects WADA / IOC list of prohibited agents and their cardiovascular effects Anabolic steroids Amphetamines Growth hormone / insulin Erythropoietin and variants Other WADA / IOC list of prohibited methods of performance enhancement Exemptions for therapeutic use Skills, attitudes and behaviours in the Core Curriculum Apart from theoretical knowledge, the trainee should have achieved a number of skills, and should display attitudes and behaviours at the end of the training period, which are essential to define him/her as a sports cardiologist. These are detailed out below. Table 1 crossreferences knowledge, skills and behaviour with the general learning objectives as laid out above. Skills Individuals training in sports cardiology require the basic skills of a good physician with a solid background in all aspects of general cardiology and sports medicine. This will provide the basis for specialized evaluation and care. More specifically, the sports cardiologist should be able to:

13 Section Sports Cardiology Core curriculum for the sports cardiologist page Recognise physiological changes as a result of athletic activity (athlete s heart) and distinguish them from those indicating possible underlying pathology. Recognise the interaction of different demographic and genetic factors. 2. Perform cardiovascular preparticipation screening independently, including interpretation of symptoms, family history, physical examination, 12-lead ECG, echocardiogram (including assessment of the right ventricle), as well as exercise ECG (with oxygen consumption measurement). Assess fitness level. Initiate additional tests if required for risk stratification. He/she should be able to distinguish physiological changes in an athlete s heart from those indicating pathology. 3. Interpret additional investigations to identify risk of coronary heart disease (blood tests, perfusion scans or stress echocardiography) or arrhythmias (like exercise ECG, Holter or event recorder tracings). 4. Provide advice relating to appropriate life style modification, including exercise prescription, in subjects with and without established heart disease, sedentary populations and those with risk factors such as hypertension, hypercholesterolemia, smoking and/or obesity. Exercise prescription should be regarded as part of management and should specify mode, intensity, duration and progression. 5. Initiate appropriate pharmacological treatment for underlying risk factors. 6. Translate the guidelines on safe participation in sports in individuals with an underlying disease into concrete advice and instructions toward the sports participants. 7. Manage patients with cardiomyopathies, arrhythmias and/or inherited diseases after active participation experience to such clinics. 8. Communicate skilfully with the athlete and with colleagues if further specialist advice is warranted. For difficult decisions that are likely to affect an athlete s eligibility to compete, it is important that the sports cardiologist does not act in isolation, but seeks the opinion/consensus of other experts and refers to specialists if appropriate (building networks). 9. Recognise substances and methods, banned during sports participation by IOC or WADA and understands their pharmacologic and potentially deleterious effects. Includes drug history in screening interviews. Respects his/her role and responsibility to protect the athlete, and can educate the athlete and coaches accordingly. Knows how to exert therapeutic exemption procedures, when appropriate. Knows how to inform relevant sport governing bodies if required.

14 Section Sports Cardiology Core curriculum for the sports cardiologist page Communicate with owners of big sport venues, organisers of mass sport events, and health community, responsible for developing a medical action plan. 11. Have a sound understanding of the research principles and mechanisms, including study design and statistical principles. Behaviour and attitudes The acquired knowledge and skills need to be part of a general attitude towards the field of sports cardiology, towards athletes, and toward the community, encompassing: 1. Appreciation of the importance of exercise in health promotion for the general population, and as integrated component of cardiac care in primary and secondary prevention. 2. An attitude of encouragement and motivation towards patients to adopt life-style modifications. 3. Active and regular participation to cardiovascular evaluation of athletes or subjects who want to engage in leisure-time sports, including regular participation in sports cardiology clinics and screening programs involving athletes of different backgrounds. 4. Ability to explain the rationale for (additional) investigations, and explain their risk/benefit ratio, in order to obtain informed consent. 5. Appreciation of the role and limitations, including sensitivity and specificity of diagnostic investigations, and their impact on the interpretation of test results. 6. Ability to balance medical recommendations against the desire of the athlete to participate and excel, while taking into account the physician s moral and societal duty to prevent harm. The athlete should be thoroughly involved in decision making, but the sports physician should be prepared to accept responsibility. 7. Ability to provide recommendations on the training of bystanders in basic life support and on the placement of automatic external defibrillators. 8. Experience in dealing with medical situations at mass sporting events based on active participation as a member of the medical teams, at a number of different roles, at such events. 9. Empathy when dealing with an athlete with a potentially serious cardiac disorder or abuse of a banned substance, with proper counselling of the athlete as well as involved third parties like family members, trainers, and club managers. Communication should not violate the patient rights of the athlete; the sports

15 Section Sports Cardiology Core curriculum for the sports cardiologist page 14 physician should be very reserved towards public and press announcements in order to protect an integer relation with the athlete. 10. Willingness to participate in continued education and professional development, by attending national or international lectures or courses. Training requirements and plan The sports cardiology curriculum necessitates a dedicated training period, during or following the general cardiology curriculum that allows the acquisition of the required knowledge and skills, and provides opportunities to develop appropriate behaviours. This section details the minimal requirements of the training programme for sports cardiologists, including duration of training, training plan, and the certification process. Training duration The duration of training should be a minimum cumulative period of 12 months, fully dedicated to the various aspects of sports cardiology, including participation to research and educational activities of the training department. Ideally, the training should be full-time and continuous, although part-time assignments of equivalent duration are acceptable, to ensure equal opportunities for all trainees. Trainee requirements The trainee should be a registered medical physician and have completed or be close to completing his/her specialist training in either cardiology or sports medicine/exercise physiology. A cardiology or an exercise physiology background is necessary not only to master the technical aspects, but also to verify the indications and contraindications of tests, to initiate and conduct investigations, and to provide an accurate and comprehensive interpretation of the clinical data. Cardiology trainees will earn a qualification in Sports Cardiology, while non-cardiology trainees will be awarded the qualification of Physician with a special interest in Sports Cardiology. Trainees with a cardiology background should either be registered cardiologists or alternatively, sports cardiology may be integrated into the final years of their general cardiology training amounting to a minimum of 1 year of cumulative experience. In a similar manner, trainee physicians with a sports medicine or exercise physiology background should either be registered sports physicians or alternatively, sports cardiology may be integrated into the final year of their training. Given the complexity of cardiology as a medical specialty (which in most countries requires a minimum of 4 years of dedicated training), and the short duration of the proposed sports cardiology curriculum, it is

16 Section Sports Cardiology Core curriculum for the sports cardiologist page 15 imperative that physicians with a sports medicine or exercise physiology background who wish to undertake sports cardiology training have already had a minimum of 6 months of experience in general cardiology. Also, candidates should have obtained an Advanced Life Support (ALS) certificate from relevant national or European resuscitation councils prior to completing the sports cardiology course. Training plan The trainee should follow a structured teaching program based on the learning objectives detailed in the previous section. The program must be comprehensive. During the training period, the trainee should participate in sports cardiology related activities for at least 80% of the working hours (based on full-time employment), or at least 40% for two years. Completion of the full training in a single centre is recommended but if a centre is unable to develop/support a comprehensive teaching program, cooperation with other centres to complete the training requirements should be sought. The original centre should remain responsible for the completion of a structured teaching program by the trainee. Exchange programs between training centres should be encouraged although the timing, duration and possible contribution towards the completion of sports cardiology training will be dictated by the national training committees/parent centres. National teaching programs (if approved by the national accreditation authority) and international educational activities (provided or endorsed by Section on Sports Cardiology of the EACPR) may supplement or substitute part of the theoretical training provided by the centre. The training plan should include clinical activities and practical training. During the training period, trainees should attend and participate in educational, clinical and research meetings dealing with sports cardiology topics. In addition, the trainee should attend at least one official international subspecialty meeting of a scientific society in the field. The trainee must be involved with research activities in the field. He/she must conduct one systematic literature review on a sports cardiology topic and should present one scientific abstract at a national or international meeting. Indicative number of procedures: Table 2 lists the absolute minimum of procedures that have to be performed or attended by the trainee. It is important that the emphasis of evaluation is on a competency assessment and not on how many procedures one has performed or attended. Performance of these procedures should be recorded in a logbook, on paper or online.

17 Section Sports Cardiology Core curriculum for the sports cardiologist page 16 Training center requirements The training centre should have an established sports cardiology theoretical curriculum and a sports cardiology or an inherited cardiac diseases clinic. It must be recognised as an official sports cardiology training centre by the national accreditation authority. The training centre should perform regular pre-participation screening sessions, physical fitness assessments, and follow-up of athletes with cardiac abnormalities. It must provide the opportunity to the trainee to obtain experience with performing first line investigations such as ECG, transthoracic echocardiography, exercise testing, Holter monitoring and fitness evaluation. The trainee should have the opportunity to attend formal multidisciplinary meetings reviewing sports cardiology topics, discussing diagnostic dilemmas and managing challenging cases. There should be an established referral pattern for athletes with detected cardiovascular abnormalities, and formal meetings with other specialists on the further management. There should be an established teaching program consisting of lectures or small group teaching, based on the sports cardiology curriculum. The training centre must encourage the trainee s attendance at official national and international subspecialty meetings and national/international sports cardiology educational events. The training centre should have a minimum level of scientific activity in exercise physiology and/or sports cardiology, which is verifiable by the presentation of at least three related scientific communications at international cardiology congresses during the previous 3 years, and by the publication of at least one scientific article related to sports cardiology in a Pubmed-cited journal during the previous 3 years. Training assessment Assessment of the training centres is of the utmost importance to ensure that training centres provide high standards of education and promote continuous improvement of their training programs. The training centre must fulfil the minimum requirements as described above. Continuous assessment of the centre should rely with the relevant national accreditation authorities or alternatively with the EACPR or the ESC. Assessment of the trainee is essential to guarantee a minimum level of knowledge and clinical competence. Assessment methods should include reports by the training program supervisor or personal tutor, a logbook of pre-specified number of diagnostic procedures and evaluations (table 2), written and practical exams, and assessment of professionalism (skills and attitudes). The progress of the trainee should be closely monitored by means of formal assessments/meetings with the educational supervisor/tutor throughout the training period. The EACPR/ESC is in the process of launching a new online educational platform (ESCeL), which will provide many of the tools for education and evaluation. The trainee should also

18 Section Sports Cardiology Core curriculum for the sports cardiologist page 17 undergo a final evaluation, which can be provided at local (university), national, or in the future possibly at European level (e.g. by EACPR certification). National authorities will dictate which evaluations are necessary for accreditation in order to register a trainee as a sports cardiologist. Continuous medical education and maintaining competence: Continuous medical education (CME) in cardiology subspecialties is important because knowledge and skills are continuously developing and evolving and the health-care environment is changing. The sports cardiologist should be able to prove at regular intervals that he/she has followed officially recognized national and international educational events, and has spent a minimum amount of professional activities in the field of sports cardiology (i.e. by attending at least one scientific meeting annually with specific sports cardiology sessions on the program). The ESCeL platform will provide tools for tracking this maintenance of professionalism. The Section of Sports Cardiology considers it as one of its duties to contribute to these developments. Funding and potential conflicts of interest HH has reported consulting fees / honoraria from Bayer, Boehringer Ingelheim, Daiichi- Sankyo, MSD, Sanofi-Aventis, Biotronik and Medtronic. He is the Coordinating Clinical Investigator of the Biotronik sponsored EuroEco trial, and receives unconditional support from Boston Scientific, St. Jude Medical and Medtronic for the European Branch of the ICD Registry in Athletes. Through the University of Leuven, he receives unconditional grants from Astra Zeneca, Medtronic, Boston Scientific and Biotronik. FC reported consulting fees / honoraria from Bayer, Menarini, MSD, Novartis and Servier. He receives research grants from the French Ministry of Youth and Sports, the French Society of Cardiology, and the Club de Cardiologues du Sport. None of the other authors reported any related potential conflict.

19 Section Sports Cardiology Core curriculum for the sports cardiologist page 18 References 1. Corrado D, Pelliccia A, Bjornstad HH, Vanhees L, Biffi A, Borjesson M, Panhuyzen- Goedkoop N, Deligiannis A, Solberg E, Dugmore D, Mellwig KP, Assanelli D, Delise P, van-buuren F, Anastasakis A, Heidbuchel H, Hoffmann E, Fagard R, Priori SG, Basso C, Arbustini E, Blomstrom-Lundqvist C, McKenna WJ, Thiene G. Cardiovascular preparticipation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J 2005;26(5): De Ceuninck M, D'Hooghe M, D'Hooghe P, Committee FaUSM. Sudden cardiac death in football. kind=64/newsid= html 3. Bille K, Figueiras D, Schamasch P, Kappenberger L, Brenner JI, Meijboom FJ, Meijboom EJ. Sudden cardiac death in athletes: the Lausanne Recommendations. European journal of cardiovascular prevention and rehabilitation : official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology 2006;13(6): Borjesson M, Urhausen A, Kouidi E, Dugmore D, Sharma S, Halle M, Heidbuchel H, Bjornstad HH, Gielen S, Mezzani A, Corrado D, Pelliccia A, Vanhees L. Cardiovascular evaluation of middle-aged/senior individuals engaged in leisure-time sport activities: position stand from the sections of exercise physiology and sports cardiology of the European Association of Cardiovascular Prevention and Rehabilitation. European journal of cardiovascular prevention and rehabilitation : official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology Corrado D, Pelliccia A, Heidbuchel H, Sharma S, Link M, Basso C, Biffi A, Buja G, Delise P, Gussac I, Anastasakis A, Borjesson M, Bjornstad HH, Carre F, Deligiannis A, Dugmore D, Fagard R, Hoogsteen J, Mellwig KP, Panhuyzen-Goedkoop N, Solberg E, Vanhees L, Drezner J, Estes NA, 3rd, Iliceto S, Maron BJ, Peidro R, Schwartz PJ, Stein R, Thiene G, Zeppilli P, McKenna WJ. Recommendations for interpretation of 12-lead electrocardiogram in the athlete. Eur Heart J 2010;31(2): Deligiannis A, Bjornstad H, Carre F, Heidbuchel H, Kouidi E, Panhuyzen-Goedkoop NM, Pigozzi F, Schanzer W, Vanhees L. ESC Study Group of Sports Cardiology Position Paper on adverse cardiovascular effects of doping in athletes. Eur J Cardiovasc Prev Rehabil 2006;13(5): Pelliccia A, Fagard R, Bjornstad HH, Anastassakis A, Arbustini E, Assanelli D, Biffi A, Borjesson M, Carre F, Corrado D, Delise P, Dorwarth U, Hirth A, Heidbuchel H, Hoffmann E, Mellwig KP, Panhuyzen-Goedkoop N, Pisani A, Solberg EE, van-buuren F, Vanhees L, Blomstrom-Lundqvist C, Deligiannis A, Dugmore D, Glikson M, Hoff PI, Hoffmann A, Horstkotte D, Nordrehaug JE, Oudhof J, McKenna WJ, Penco M, Priori S, Reybrouck T, Senden J, Spataro A, Thiene G. Recommendations for competitive sports participation in

20 Section Sports Cardiology Core curriculum for the sports cardiologist page 19 athletes with cardiovascular disease: A consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J 2005;26(14): Borjesson M, Assanelli D, Carre F, Dugmore D, Panhuyzen-Goedkoop NM, Seiler C, Senden J, Solberg EE. ESC Study Group of Sports Cardiology: recommendations for participation in leisure-time physical activity and competitive sports for patients with ischaemic heart disease. Eur J Cardiovasc Prev Rehabil 2006;13(2): Heidbuchel H, Corrado D, Biffi A, Hoffmann E, Panhuyzen-Goedkoop N, Hoogsteen J, Delise P, Hoff PI, Pelliccia A. Recommendations for participation in leisure-time physical activity and competitive sports of patients with arrhythmias and potentially arrhythmogenic conditions. Part II: ventricular arrhythmias, channelopathies and implantable defibrillators. Eur J Cardiovasc Prev Rehabil 2006;13(5): Heidbuchel H, Panhuyzen-Goedkoop N, Corrado D, Hoffmann E, Biffi A, Delise P, Blomstrom-Lundqvist C, Vanhees L, Ivarhoff P, Dorwarth U, Pelliccia A. Recommendations for participation in leisure-time physical activity and competitive sports in patients with arrhythmias and potentially arrhythmogenic conditions Part I: Supraventricular arrhythmias and pacemakers. Eur J Cardiovasc Prev Rehabil 2006;13(4): Borjesson M, Serratosa L, Carre F, Corrado D, Drezner J, Dugmore DL, Heidbuchel HH, Mellwig KP, Panhuyzen-Goedkoop NM, Papadakis M, Rasmusen H, Sharma S, Solberg EE, van Buuren F, Pelliccia A. Consensus document regarding cardiovascular safety at sports arenas: position stand from the European Association of Cardiovascular Prevention and Rehabilitation (EACPR), section of Sports Cardiology. European Heart Journal 2011;32(17): (2008) The ESC core curriculum for the general cardiologist. Prepared by the Education Committee of the European Society of Cardiology Merino JL, Arribas F, Botto GL, Huikuri H, Kraemer LI, Linde C, Morgan JM, Schalij M, Simantirakis E, Wolpert C, Villard MC, Poirey J, Karaim-Fanchon S, Deront K. Core curriculum for the heart rhythm specialist. Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology 2009;11 Suppl 3:iii1-26.

21 Section Sports Cardiology Core curriculum for the sports cardiologist page 20 Table 1: Correspondence of knowledge (core syllabus), skills, and behaviour and attitudes to the general objectives of the Core Curriculum for the sports cardiologist Learning objective Knowledge Skills Behaviour and attitudes (corresponding curriculum sections) 1. To appreciate the principles of exercise physiology, the acute and chronic (structural and functional) cardiac adaptations to exercise and the influence of age, gender, ethnicity, genetics and sporting discipline. Section 1 To be able to recognise physiological changes as a result of athletic activity (athlete s heart) and distinguish them from those indicating possible underlying pathology. Recognise the interaction of different demographic and genetic factors. Regular participation in sports cardiology clinics and screening programs involving athletes of different backgrounds. 2. To appreciate the benefits of exercise on reducing cardiovascular risk. Section 1 Provide advice relating to appropriate life style modification, including exercise, in subjects without known underlying disease and/or with risk factors such as hypertension, hypercholesterolemia, smoking and/or obesity. Exercise prescription should specify mode, intensity, duration and progression. Initiate appropriate pharmacological treatment for underlying risk factors. Appreciation of the importance of exercise in health promotion for the general population, and as integrated component of cardiac care in secondary prevention. To encourage and motivate patients to adopt relevant life-style modifications.

22 Section Sports Cardiology Core curriculum for the sports cardiologist page To be able to perform competently/supervise, select appropriately and interpret correctly the following investigations in the athlete: - 12-lead ECG - Exercise test - Ambulatory ECG - Signal average ECG - Provocation tests - Basic echocardiography - Familial screening Section 2 Demonstrate ability to perform, supervise and interpret non-invasive tests. Demonstrate appreciation of the role and limitations of non-invasive tests. Demonstrate appreciation of the sensitivity, specificity and predictive accuracy of non-invasive tests. 4. To demonstrate understanding of the role of: - MRI - Other imaging studies - Functional studies - Electrophysiological studies - Detraining - Genotyping Section 2 Demonstrate the ability to understand the results of further studies and integrate them with those of other investigations in clinical practice. Demonstrate appreciation of the strengths and limitations of advanced studies. 5. To demonstrate in depth understanding and ability to diagnose conditions predisposing to SCD in athletes, as well as differentiate such conditions from physiological adaptation. Sections 1, 2, 3 and 5 To obtain comprehensive knowledge of conditions predisposing to SCD in athletes. Demonstrate understanding of the challenges of differentiating athlete s heart from cardiomyopathy. Regular participation in sports cardiology and inherited cardiac diseases clinics. Participation in multidisciplinary meetings where challenging cases are discussed and debated. 6. To conduct cardiovascular preparticipation screening in order to Sections 2, 3, 4 and 7 To perform cardiovascular preparticipation screening independently, including correct Active and regular participation to cardiovascular evaluation of

23 Section Sports Cardiology Core curriculum for the sports cardiologist page 22 prevent sudden cardiac death in athletes, and to appreciate the ethical and legal aspects of screening. interpretation of symptoms, physical examination and ECG and initiate additional tests as required. athletes or subjects who want to engage in leisure-time sports. 7. To perform appropriate investigations, risk stratification and management in athletes and patients with cardiac disease. Sections 2, 3, 6, 8 Initiate and Interpret additional investigations to risk stratify athletes and patients with cardiac disease including coronary heart disease. Manage athletes with relatively rare cardiomyopathies, arrhythmias and/or inherited diseases, including the initiation of appropriate pharmacological therapy. Regular active participation in inherited cardiac diseases and sports cardiology clinics. Understanding the limitations concerning sensitivity and specificity of diagnostic investigations, and their impact on the interpretation of test results. 8. To monitor safe resumption of physical/sport activities in athletes or patients with cardiac disease. Sections 6 and 8 Translate the guidelines on safe participation in sports in individuals with an underlying disease into concrete advice and instructions toward the sports participant. Communicate skilfully with the athlete and with colleagues if further specialist advice is warranted. For difficult decisions that are likely to affect an athlete s eligibility to compete, it is important that the sports cardiologist does not act in isolation, but seeks the opinion / consensus of other experts and refers to specialists if appropriate. Ability to balance medical recommendations against the desire of the athlete to participate and excel, while taking into account the physician s moral and societal duty to prevent harm. The athlete should be thoroughly involved in decision making, but the sports physician should be prepared to accept responsibility. 9. To be competent at basic and advanced cardiac life support. Section 8 Have practical experience to carry out basic and advanced cardiac life support, including the use of external (automatic) defibrillators. Ability to provide recommendations on the training of bystanders in basic life support and on the placement of automatic external

24 Section Sports Cardiology Core curriculum for the sports cardiologist page 23 The candidates should have obtained an Advanced Life Support (ALS) certificate prior to completing the sports cardiology course defibrillators. 10. To manage and develop safety procedures in sports arenas. Section 9 Communicate with owners of big sport venues, organisers of mass sport events, and health community responsible for developing a medical action plan. Experience in dealing with medical situations at mass sporting events based on active participation as a member of medical teams at such events. 11. To appreciate the cardiovascular effects of substance abuse/doping. Section 10 To recognise substances and methods, banned during sports participation by IOC or WADA, and understand their pharmacologic and potentially deleterious effects. To Include drug history in screening interviews. To respects its role and responsibility to protect the athlete, and can educate athletes and coaches accordingly. Knows how to exert therapeutic exemption procedures, when appropriate. Knows how to inform relevant sport governing bodies if required. Empathy when dealing with an athlete with a potentially serious cardiac disorder or abuse of a banned substance, with appropriate counselling of the athlete as well as involved third parties like family members, trainers, and club managers. Communication should not violate the patient rights of the athlete; the sports physician should be very reserved towards public and press announcements in order to protect an integer relation with the athlete. 12. To demonstrate effective communication and teaching skills including breaking bad news. Sections 1, 7 To educate sports participants and the general population relating to the value of sports activities and physical exercise on reducing cardiovascular risk factors and optimizing health. To

25 Section Sports Cardiology Core curriculum for the sports cardiologist page 24 communicate effectively with athletes undergoing preparticipation screening and explain the rationale for (additional) investigations, and explain their risk/benefit ratio, in order to obtain full informed consent. 13. To demonstrate awareness of up to date evidence based practices, knowledge of different research methodologies and perform audit of clinical practice and apply findings appropriately. All sections Have a sound understanding of the research principles and mechanisms, including study design and statistical principles. Willingness to participate in continued education and professional development, by attending national or international lectures or courses.!

26 Section Sports Cardiology Core curriculum for the sports cardiologist page 25 Table 2: Absolute minimum of procedures that the trainee should attend/observe and perform during the curriculum Type Attend/Observe Actively perform/interpret 12-lead ECG Transthoracic echocardiogram Exercise testing Cardiopulmonary exercise testing Analysis of rhythm recording (Holter, event recorders) Signal average ECG Fitness assessments Pre-participation screening sessions, including History taking Perform clinical examination Interpret 12-lead ECG Interpret overall findings and formulate management plan Communicate results to the athlete Arrange appropriate further investigations/follow-up Return to play program Sports cardiology/inherited cardiac diseases clinics Mass sporting events as a member of the medical team 1 1 Sports cardiology conference (National or International) 1 0 Present a scientific abstract 1 1 Conduct and present a systematic review to his peers 1 1

27 Section Sports Cardiology Core curriculum for the sports cardiologist page 26 Figure'legends'' Figure 1 Sports Cardiology derives its inception from the ancient awe for athletic achievements, the recognition that habitual exercise is an antidote to the cardiovascular risks of the modern diet and lifestyle, but also from the acknowledgement of the inherent risks of athletic excellence in predisposed individuals. Painting by Luc-Olivier Merson, 1869, of Pheidippides as he gave word of the Greek victory over Persia at the Battle of Marathon to the people of Athens. Having ran 40 km from the battlefield near Marathon to Athens and collapsed and died on the spot after shouting Nenikékamen, "We have won". He is reportedly the first recorded victim of exercise related sudden cardiac death. Over the years the image of a collapsed athlete, an individual who is considered to epitomise health and physical prowess, remains as shocking as ever. Figure 2 Every year a large number of athletes undergo cardiovascular evaluation as part of their regular fitness assessment, preparticipation screening and occasionally due to symptoms which raise concern of an underlying heart disease. Participation in regular exercise is associated with electrocardiographic and echocardiographic changes collectively referred as the Athlete s Heart. Such changes may overlap with those observed in cardiomyopathies. Differentiation between phenotypes that correspond to athletic activity and those that denote cardiac disease may be challenging and requires considerable experience and training. Figure 3 Flowchart of trainee requirements and principle elements of the curriculum for the Sports Cardiology qualification.

28 Section Sports Cardiology Core curriculum for the sports cardiologist page 27 Figure'1'!

29 Section Sports Cardiology Core curriculum for the sports cardiologist page 28 Figure'2'