key: cord-0888400-rav3pk2l
authors: Choi, Andrew D.; Thomas, Dustin M.; Lee, James; Abbara, Suhny; Cury, Ricardo; Leipsic, Jonathon A.; Maroules, Christopher; Nagpal, Prashant; Steigner, Michael L.; Wang, Dee Dee; Williams, Michelle C.; Zeb, Irfan; Villines, Todd C.; Blankstein, Ron
title: 2020 Guideline for Training Cardiology and Radiology Trainees as Independent Practitioners (Level II) and Advanced Practitioners (Level III) in Cardiovascular Computed Tomography: A Statement from the Society of Cardiovascular Computed Tomography (SCCT)
date: 2020-08-14
journal: Journal of Cardiovascular Computed Tomography
DOI: 10.1016/j.jcct.2020.08.003
sha: f5b83aca9fcd812838d621a8a906c152358577cd
doc_id: 888400
cord_uid: rav3pk2l

Abstract Cardiovascular computed tomography (CCT) is a well-validated non-invasive imaging tool with an ever-expanding array of applications beyond the assessment of coronary artery disease. These include the evaluation of structural heart diseases, congenital heart diseases, peri-procedural electrophysiology applications, and the functional evaluation of ischemia(1). This breadth requires a robust and diverse training curriculum to ensure graduates of CCT training programs meet minimum competency standards for independent CCT interpretation. This statement from the Society of Cardiovascular Computed Tomography aims to supplement existing societal training guidelines by providing a curriculum and competency framework to inform the development of a comprehensive, integrated training experience for cardiology and radiology trainees in CCT.

The field of cardiovascular computed tomography (CCT) has seen considerable growth over the past decade. Driven in large part by a growing body of evidence and significant advancements in scanner technology, societal guidelines internationally now strongly recommend CCT, as the preferred first-line test in patients without known coronary artery disease (1) (2) (3) . The recently updated National Institute for Health and Care Excellence (NICE) guidelines in the United Kingdom (UK) recommend CCT as the preferred testing strategy for stable chest pain patients without known CAD, citing accuracy of diagnosis, as well as economic and prognostic advantages (4, 5) . One challenge facing this increased utilization of CCT in the UK is the need for more independent CCT practitioners and/or advanced practitioners capable of leading a CCT laboratory (6) . In the US, data from recent clinical trials, and an increased emphasis on value based care are contributing to a similar shift toward increased utilization of CCT, and thus a similar need for a higher number of independent CCT readers (7) (8) (9) . This is expected to drive a similar need for more independent and advanced CCT practitioners.

In addition to the evaluation of CAD, the role for CCT in the evaluation of structural cardiac disease continues to expand rapidly, is now a prerequisite imaging study for the optimal planning of transcatheter, surgical and congenital therapies, and is expected to further evolve in the future (10, 11) .

The modern cardiology and radiology trainee pursuing CCT training should be comfortable with the scope and fundamentals of these various non-coronary applications. In the United States, societal training guidelines from the American College of Cardiology (ACC) and American College of Radiology (ACR) inform the case volume and clinical skills that are required to become accredited as an independent reader or as a laboratory director (12, 13) .

Internationally, several training statements incorporate CCT training. The 2014 Royal College of Radiologists/British Society of Cardiovascular Imaging document addresses the safe practice of CT coronary angiography (14) . The European Association of Cardiovascular Imaging developed a CCT Core J o u r n a l P r e -p r o o f Syllabus in 2015 that gives a broad overview to educational topics that constitute competency for CCT practice (15) . Recently, the Royal College of Radiology Clinical Radiology Specialty Training Curriculum 2020 has incorporated CCT training (16) . The Society of Cardiovascular Computed Tomography (SCCT) published a statement in 2015 outlining a comprehensive curriculum for cardiology and radiology program directors to design an educational experience in the basic, foundational (level I) aspects of CCT (17) . To complement these statements, there is a need to assist program directors in designing a comprehensive academic curriculum to address advanced level trainees capable of performing and interpreting complex studies, lead a research program, direct a CCT laboratory and/or train others in CCT.

This document strives to provide guidance for program directors (PD) charged with designing a curriculum for the training of Independent Practitioner (IP; Level II) and/or Advanced Practitioner (AP; Level III) ( Table 1 ). In the U.S., the Accreditation Council for Graduate Medical Education (ACGME) adopted a set of 6 core competencies that make up the cornerstone trainee education and assessment: 1) medical knowledge; 2) practice-based learning and improvement (PBLI); 3) patient care and procedural skills; 4) systems-based practice; 5) interpersonal and communication skills; and 6) professionalism.

Furthermore, this document uses the framework of the ACGME core competencies as a global document to enable the assessment and education of trainees across these core competencies to reproducibly train graduating fellows and residents fully qualified to care for patients utilizing CCT.

Thus, this document aims to reinforce learning competencies utilized regularly in clinical practice through daily case volume. It also aims to provide a guide for necessary medical knowledge and online case volume supplementation needed to expose the trainee to less frequently encountered CCT applications.

J o u r n a l P r e -p r o o f CCT trainees emerge from two principle training backgrounds: radiology or cardiology. Importantly, it is not so much what specialty a prospective CCT reader originates from, but rather the quality of dedicated training that they obtain that ultimately defines competency level and expertise in the advanced field of CCT. Indeed, the strong collaboration between radiologists and cardiologists -in clinical practice, research, and in training -has fueled many of the advances in the field of CCT (18) . The challenge for radiology and cardiology PDs is to identify training gaps in their respective curriculum and augment the training experience to incorporate all necessary learning objectives, regardless of local expertise, case diversity, or case volume.

Additionally, consideration should be given to tailoring a training curriculum based specifically on augmenting known knowledge gaps. Cardiology fellows, as an example, may require a training curriculum weighted more heavily in CT physics, protocol optimization, and extra-cardiac anatomy, and pathology. Conversely, radiology residents may benefit from a training curriculum focused more on cardiac anatomy, clinical outcomes data, clinical practice guidelines, management of cardiovascular disease, and cardiac pathophysiology. Figure 1 outlines potential CCT training pathways for both cardiology fellows and radiology residents. Given local variations in case volume, diversity, and supervisor expertise, training duration for IP/Level II trainees may vary.

Less variability typically exists with respect to IP training for radiology residents. General curriculum requirements are completed during the first 3 years of training and IP requirements are accomplished during focused cardiac imaging training, typically during the fourth year of training. For radiology and nuclear medicine residents, the American College of Radiology (ACR) released an update to CT accreditation program requirements in July 2015 (19) . The ACR statement lays out minimum initial J o u r n a l P r e -p r o o f requirements with respect to CCT case volume, board certification and/or training, and additional education in cardiac structure and function in order to interpret and supervise CCT examinations.

More recently in 2016, a joint practice parameter collaboratively revised by ACR in concert with the North American Society of Cardiovascular Imaging (NASCI) and the Society of Pediatric Radiology (SPR) was published that differs slightly from the 2015 ACR statement (13) . The joint 2016 practice parameter lowered the number of dedicated cardiac CT examinations performed to 50 studies over a 36 month period (compared with 75 in the 2015 ACR CT accreditation requirements statement) while also lowering the required continuing medical education (CME) hours to 30 (from 40 hours); while maintaining board certification and training program accreditation standards established in the 2015 ACR statement. Importantly, the 2016 joint practice parameter also outlined qualifications required to assume responsibility of a cardiac CT imaging program or laboratory. In addition to the previously discussed requirements, an additional 450 supervised thoracic CT or CT angiography cases, excluding CAC scoring, are required and an additional 200 hours of CT-specific CME.

Nuclear medicine training is much more variable as trainees can emerge from both internal medicine and radiology. Thus, these trainees should follow guidance found in the ACR statement (19) . In brief, radiology trainees are required to successfully complete board certification through a recognized governing body (i.e. American Board of Radiology, Royal College of Physicians and Surgeons of Canada, etc). Importantly, no distinction is made between IP and AP levels of competency. (20) . While the 2015 ACR statement mentions training recommendations for IPs originating from a cardiology background, training requirements for various levels of competency for cardiology fellows are governed by the Core Cardiovascular Training Statement (COCATS) published by the American College of Cardiology (12) . COCATS 4 provides a case-volume recommendations, in addition to general ACGME core competency-based training objectives ("milestones") for both Level I and Level II general cardiology fellows (12) . Training requirements highlighted in COCATS 4 call for significant hands-on time spent with contrast-enhanced CCT dataset acquisition and patient preparation with a focus on mentored case review at a 3-dimenstional (3D) workstation. In general, level I concepts should be met within the first 2 years of fellowship training with more focused case exposure and didactic training required in the 3 year of training to achieve Level II competency during a standard general cardiology fellowship.

Advanced Practitioner (Level III) AP learners requires additional training in hybrid imaging modalities, participation in the various aspects of laboratory administration, education of cardiology and/or radiology trainees, and participation in CCT-specific research. In addition to devoted training in CCT, an AP trainee is required to achieve advanced training in at least 1 additional imaging modality. Given these extensive requirements, COCATS recommends additional training beyond the standard 3-year fellowship, though this is not explicitly required. In the U.S. multiple cardiovascular imaging fellowships are available that enable trainees to acquired advanced knowledge and skills that enable trainees to achieve level II or level III in multiple imaging modalities. Around the world CCT is an important component of standard cardiology curriculum. For example in the UK, the Joint Royal Colleges of Physicians Training Board incorporates J o u r n a l P r e -p r o o f CCT in its specialty training curriculum for cardiology trainees (21) . In addition, the length of cardiology training varies widely, and additional training in CCT may be required to achieve AP level.

Taking this background into account, the purpose of this statement is threefold. First, we seek to expand upon the SCCT general (Level I) curriculum guideline statement by providing knowledge and skills required for IP and AP trainees. Second, we seek to provide enhanced granularity and standardization across advanced imaging fellowship curricula and across a broad range of training backgrounds (radiology and cardiology). Finally, we seek to fill in identified gaps in currently published training recommendation statements and emphasize that background knowledge and procedural skill are important requirements delineated in the COCATS and ACR statements. Specifically, this document delineates a suggested minimum threshold for AP case volumes to achieve the milestones outlined. This guideline is not meant to supersede the existing COCATS and ACR statements, but rather complement those documents to encompass the most recent advancements in the field of CCT.

As this document builds upon the curriculum previously outlined in the 2015 SCCT Level I curriculum guideline (17), a comprehensive training curriculum with a goal of producing competent IP and AP imagers should be tailored to the specific strengths and limitations of training background (cardiology, radiology, or nuclear medicine), total laboratory case volume, and case diversity. Building an initial curriculum or revamping an existing curriculum for IP and AP trainees is a complex undertaking.

Radiology residents/trainees may have a stronger foundation in CT scanner strengths, limitations, protocol selection, post-processing, and image manipulation. Cardiology fellows/trainees may have a J o u r n a l P r e -p r o o f deeper understanding of cardiac anatomy, physiology, pathologic disease states, and the clinical applicability of these various findings, but minimal exposure to CT as an imaging modality. A team-based approach to the hands-on scanner training experience, which could involve technologist, medical physics, and the laboratory director, could also increase the level of understanding and depth of knowledge. In addition, AP trainees may require exposure to multiple scanner platforms and to a diverse case volume that should involve multi-disciplinary image interpretation and clinical correlation of findings.

Understanding that a critical review and potential revision of a CCT training curriculum can be time consuming, this document seeks to ease this transition in several ways. First, recommended learning objectives are found in Table 2 and are arranged by ACGME core competency and further broken down by core CCT domain for both IP and AP trainees. The ACGME core competencies were used to allow for PDs to more easily develop trainee evaluations to ensure learners are meeting specific milestones and to identify knowledge gaps earlier in training where they can more easily be addressed.

Case volume and diversity are important aspects for potential IP & AP trainees, as there is data linking increasing case volumes with successful completion of board certification examinations (22) . Of greater importance, the case volumes discussed within this document serve as a starting point for competency that must be assessed and verified by CCT advanced practitioners. This can be learned and evaluated during live case manipulation at a dedicated 3D workstation. It is important that IP & AP trainees be directly mentored by a supervising faculty with routine involvement in image acquisition and protocol selection at the scanner. In many institutions, though, there is limited case volume and diversity that is reliably available for all trainees and thus alternative training resources are needed.

Supplementation with electronic teaching files and/or online resources with emphasis on maximal exposure to 3D workstation functionality may assist with bridging this gap.

Integration and leveraging of expertise from cardiology and radiology resources within a training center can significantly augment an IP and AP training curriculum (18) . PDs are strongly encouraged to coordinate with these other departments to arrange for multidisciplinary conferences, multimodality imaging correlations, and joint live interpretation at the 3D workstation. With regard to minimum case volumes for IP and AP competency (Tables 3, 4 and 5), the writing group arrived at these recommendations through unanimous consensus.

The widespread adoption of transcatheter aortic valve replacement (TAVR) has driven a strong interest in the field of structural heart disease. During the development of TAVR, CCT has become integral to the preprocedural planning of these procedures which has increased the need for competent IPs and APs with specific expertise and dedicated training in SHD (10, (23) (24) (25) (26) (27) . Furthermore, the role of CCT in newer technologies such as left atrial appendage (LAA) occlusion device implantationand the systematic evaluation of left ventricular assist devices (LVADs) continues to expand due to the distinct advantages from a spatial resolution perspective (28) (29) (30) (31) . Within the realm of transcatheter mitral valve replacement (TMVR), pre procedural CCT is a requirement in device selection, left ventricular outflow tract obstruction prediction risk, and intraprocedural fusion road mapping (27, 32, 33) .

The application of CCT in structural heart disease is not significantly addressed in any prior societal training guidelines (26) . However, it is important that all IP and AP trainees receive at least introductory exposure to this field with didactic content incorporating learning objectives from Table 2 including an understanding of vascular access. While case volume and didactics can provide an initial training experience to structural heart disease, more advanced training requires dedicated time with J o u r n a l P r e -p r o o f regular attendance at multi-specialty heart team conferences to fully understand the procedure, potential complications/pitfalls, and minimum equipment requirements as part of a 360-degree learning experience. Multi-specialty "heart team" conferences typically include an expert in CCT imaging, In addition to CCTs ability to diagnose coronary atherosclerosis anatomically, there are emerging CCT applications that allow for functional assessment of ischemia, most notably CT perfusion (CTP) and

CT-based fractional flow reserve (FFR-CT) (37) . Ideally, a multi-disciplinary heart team conference will leverage local expertise amongst CCT, nuclear cardiology, cardiac MR, echocardiography, and interventional cardiology to provide a valuable forum for open discussion on strengths, weaknesses, and appropriate use of the respective modalities (38) . Table 2 outlines important learning objectives pertaining to functional assessment by CCT. In general, both IP and AP trainees should demonstrate understanding of the current clinical role, supporting data, techniques, strengths, and weaknesses of CTbased techniques for functional assessment of CAD lesions, and how these tests may compare with other imaging techniques. As many training centers may not have readily available access to specific functional CT techniques, including CTP or FFR-CT, hands-on experience during training is not required to meet competency objectives for IP or AP trainees.

While a large proportion of the IP & AP training curriculum can be administered in conjunction with live case review, a full didactic curriculum is vital to supplement where gaps in training supervisor or case diversity exist. A didactic curriculum should incorporate multispecialty lectures from local experts complimented with webinars, societal educational offerings, and attendance at annual scientific meetings. Figure 2 and 3 highlight the comprehensive, multi-faceted approach that is needed to meet the needs of an IP and AP learner in the current era of CCT. Table 6 lists supplemental reading of societal guidelines, appropriate use criteria and key articles germane to an understanding of CCT for IP and AP trainees. Online training, webinars and simulation environments may be a useful learning adjunct in lower volume or smaller programs to supplement lower volume centers and less common CCT applications.

With respect to the AP trainee curriculum (Figure 3) , the didactic training focus should pivot toward more complex applications of CCT and complex cardiac disease. Additionally, a broader focus on integrating into a multidisciplinary team and leveraging the advanced skills of both cardiology and radiology is needed. Finally, a comprehensive AP curriculum should involve direct mentorship by the laboratory director or other AP supervisors so that education in the business and administrative aspects of leading a CCT lab are incorporated. AP trainees, in addition to a comprehensive understanding of the learning objectives, require a curriculum incorporating mentorship opportunities with the laboratory director. This could include involvement with new equipment purchases, personnel management, protocol development, and performance improvement (PI)/quality assessment (QA). Particularly with the changing landscape of medical reimbursement and payer structures, a strong foundation in quality and appropriate use is vital to a future laboratory director or PD. Specific to the ACGME, requirements have been put in place for residencies and fellowships to actively participate in PI or QA projects as part of graduation requirements. Table 7 lists several recommendations for CCT-specific QA/PI projects.

The rapid growth and expansion of CCT requires training programs to adopt a comprehensive training curriculum in order to meet the growing need for IP and AP that possess a minimum experience and core understanding of all aspects of CCT. As new technologies continue to emerge ( Table 1 • Achieved competency to independently interpret cardiac findings on non-contrast and predominantly contrastenhanced cardiac CT

• Achieved competency to independently evaluate patient selection, preparation, scan protocol selection, dose modulation, post-processing, and image interpretation • Achieved competency in all of the common cardiac CT applications to include evaluation of coronary pathology, coronary anatomy, basic structural HD assessment, EP procedural planning, basic congenital HD, and functional CT Advanced Practitioner (AP)

• Achieved competency in all capabilities ascribed to IP level of training • Achieved advanced skills and knowledge beyond IP, including evaluation of complex coronary artery disease, competency in structural heart planning and a wider spectrum of congenital heart disease • Achieved competency in vascular CT • Achieved competency in laboratory accreditation requirements and maintenance • Achieved competency in equipment purchasing, maintenance, and acquisition • Actively involved in quality improvement, performance improvement, and/or CT-specific research endeavors • Achieved competency in business aspects (billing, coverage, reimbursement, and prior authorization) of CT laboratory administration Trainees are also directed to Table 8 for a discussion on potential future curriculum competencies in this rapidly evolving field. 

Cardiac computed tomography in current cardiology guidelines

multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force

ESC Guidelines for the diagnosis and management of chronic coronary syndromes

National Institute for Health and Care Excellence (NICE): Chest pain of recent onset: assesssment and diagnosis

The rationale for the primacy of coronary CT angiography in the National Institute for Health and Care Excellence (NICE) guideline (CG95) for the investigation of chest pain of recent onset

Challenges in delivering computed tomography coronary angiography as the first-line test for stable chest pain

Defining Quality in Cardiovascular Imaging: A Scientific Statement From the American Heart Association

Availability and Location of Cardiac CT and MR Services in Massachusetts

ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

European Association for Cardio-Thoracic Surgery, Heart Valve Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons

Computed tomography imaging in the context of transcatheter aortic valve implantation (TAVI) / transcatheter aortic valve replacement (TAVR): An expert consensus document of the Society of Cardiovascular Computed Tomography

COCATS 4 Task Force 7: Training in Cardiovascular Computed Tomographic Imaging

North American Society of Cardiovascular Imaging (NASCI), and the Society of Pediatric Radiology (SPR) Practice Parameter for the Performance and Interpretation of Cardiac Computed Tomography (CT) -Resolution

Royal College of Physicians, British Society of Cardiovascular Imaging: Standards of practice of computed tomography coronary angiography (CTCA) in adult patients

Cardiac computed tomography core syllabus of the European Association of Cardiovascular Imaging (EACVI)

The Royal College of Radiologists: Clinical Radiology: 2020 Specialty Training Curriculum

SCCT curriculum guidelines for general (level 1) cardiovascular CT training

Building Bridges in Cardiology and Radiology: Why Collaboration Is the Future of Cardiovascular Imaging

ACR CT Accreditation Program Requirements

COCATS 4 Task Force 1: Training in Ambulatory, Consultative, and Longitudinal Cardiovascular Care

Relationship between previous training and experience and results of the certification examination in cardiovascular computed tomography

SCCT expert consensus document on computed tomography imaging before transcatheter aortic valve implantation (TAVI)/transcatheter aortic valve replacement (TAVR)

Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery

Computed Tomography Imaging in the Context of Transcatheter Aortic Valve Implantation (TAVI)/Transcatheter Aortic Valve Replacement (TAVR): An Expert Consensus Document of the Society of Cardiovascular Computed Tomography

Navigating a Career in Structural Heart Disease Interventional Imaging

Core Competencies in Cardiac CT for Imaging Structural Heart Disease Interventions: An Expert Consensus Statement

CT imaging for left atrial appendage closure: a review and pictorial essay

CT of left ventricular assist devices. Radiographics : a review publication of the

Expert Recommendations on Cardiac Computed Tomography for Planning Transcatheter Left Atrial Appendage Occlusion

Application of 3-Dimensional Computed Tomographic Image Guidance to WATCHMAN Implantation and Impact on Early Operator Learning Curve: Single-Center Experience

Mitral Annular Evaluation With CT in the Context of Transcatheter Mitral Valve Replacement

Validating a prediction modeling tool for left ventricular outflow tract (LVOT) obstruction after transcatheter mitral valve replacement (TMVR)

Development of a congenital cardiovascular computed tomography imaging registry: Rationale and implementation

Computed Tomography Imaging in Patients with Congenital Heart Disease Part I: Rationale and Utility. An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT): Endorsed by the Society of Pediatric Radiology (SPR) and the North American Society of Cardiac Imaging (NASCI)

Computed Tomography Imaging in Patients with Congenital Heart Disease, Part 2: Technical Recommendations. An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT): Endorsed by the Society of Pediatric Radiology (SPR) and the North American Society of Cardiac Imaging (NASCI)

Fractional flow reserve and myocardial perfusion by computed tomography: a guide to clinical application

Non-invasive Heart Team assessment of multivessel coronary disease with coronary computed tomography angiography based on SYNTAX score II 47

Society of Cardiovascular Computed Tomography guidance for use of cardiac computed tomography admist the COVID-19 pandemic. Endorsed by the American College of Cardiology

SCCT/STR guidelines for coronary artery calcium scoring of noncontrast noncardiac chest CT scans: A report of the Society of Cardiovascular Computed Tomography and Society of Thoracic Radiology

Clinical indications for coronary artery calcium scoring in asymptomatic patients: Expert consensus statement from the Society of Cardiovascular Computed Tomography

CAC-DRS: Coronary Artery Calcium Data and Reporting System. An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT)

PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Societies ESCNC. 2019 ESC/EAS guidelines for the management of dyslipidaemias: Lipid modification to reduce cardiovascular risk

ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Assessment of coronary artery disease by cardiac computed tomography: a scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology

SCCT guidelines for the interpretation and reporting of coronary CT angiography: A report of the Society of Cardiovascular Computed Tomography Guidelines Committee

ACR Appropriateness Criteria((R)) Imaging for Transcatheter Aortic Valve Replacement

Evaluation of valvular disease by cardiac computed tomography assessment

Analysis of ventricular function by CT

Interpreting results of coronary computed tomography angiography-derived fractional flow reserve in clinical practice

Myocardial Assessment with Cardiac CT: Ischemic Heart Disease and Beyond

The role of computed tomography myocardial perfusion imaging in clinical practice

Society of cardiovascular computed tomography expert consensus document on myocardial computed tomography perfusion imaging

The Future of Cardiovascular Computed Tomography: Advanced Analytics and Clinical Insights

ACCF/AHA 2007 clinical competence statement on vascular imaging with computed tomography and magnetic resonance. A report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training

Vascular CT and MRI: a practical guide to imaging protocols

Computed Tomography Angiography of the Upper Extremities

Computed Tomography Angiography of the Thoracic Aorta

Computed Tomographic Angiography of the Abdominal Aorta

Computed Tomography Angiography of the Small Bowel and Mesentery

Computed Tomograpy Angiography of the Renal Circulation

Computed Tomography Angiography of the Lower Extremities

Assist Device. CHD = Congenital Heart Disease. BAV = Bicuspid aortic valve

PFO = Patent Foramen Ovale; VSD = Ventricular Septal Defect

TGA = Transposition of the Great Arteries

Magnetic Resonance. CTP = Computed Tomography Perfusion. FFR = Fractional Flow Reserve

Practice Parameter for the Performance and Interpretation of Cardiac Computed Tomography CCT Acquisition, Interpretation and Reporting Abbara S et al (44) -SCCT guidelines for the performance and acquisition of coronary computed tomographic angiography: a report of the Society of Cardiovascular Computed Tomography Guidelines Committee Endorsed by the North American Society for Cardiovascular Imaging (NASCI)

CAD-RADS™ Coronary Artery Disease-Reporting and Data System Thomas et al (46) -Management of Coronary Artery Calcium and Coronary CTA Findings Truong et al (47)-Coronary computed tomography in women: An expert consensus statement from the SCCT Choi et al -SCCT guidance for use of CCT Amidst the COVID-19 pandemic: Endorsed by the

2016 SCCT/STR guidelines for coronary artery calcium scoring of noncontrast noncardiac chest CT scans: A report of the SCCT and Society of Thoracic Radiology Hecht HS et al (50) -Clinical indications for coronary artery calcium scoring in asymptomatic patients: Expert consensus statement from the SCCT Hecht HS et al (51) -CAC-DRS: Coronary Artery Calcium Data and Reporting System

2018 Multisociety Guideline on the Management of Blood cholesterol: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

ESC/EAS guidelines (53) for the management of dyslipiademias: lipid modification to reduce cardiovascular risk

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the ACC/AHA Task Force on Clinical Practice Guidelines Coronary Artery Disease Pathology and Guidelines Budoff et al (55)-Assessment of Coronary Artery Disease by Cardiac Computed Tomography Leipsic et al (56) -SCCT guidelines for the interpretation and reporting of coronary CT angiography: a report of the Society of Cardiovascular Computed Tomography Guidelines Committee National Institute for Health and Care Excellence (NICE) guidelines

ESC Guidelines for the diagnosis and management of chronic coronary syndromes

Structural Heart Disease Blanke et al (25) -Computed tomography imaging in the context of transcatheter aortic valve implantation (TAVI) / TAVR: An expert consensus document of the SCCT Leipsic et al (57) -ACR Appropriateness Criteria® Imaging for Transcatheter Aortic Valve Replacement Blanke et al (32) -Mitral Annular Evaluation with CT in the Context of Transcatheter Mitral Valve Replacement

CT imaging for left atrial appendage closure: a review and pictorial essay Carr et al (29) -CT of Left Ventricular Assist Devices Korsholm et al (30) -Expert Recommendations on Cardiac Computed Tomography for Planning Transcatheter Left Atrial Appendage Occlusion Leipsic et al .(27) Core Competencies in Cardiac CT for Imaging Structural Heart Disease Interventions: An Expert Consensus Statement Congenital Heart Disease Han et al

Interpreting results of coronary computed tomography angiography-derived fractional flow reserve in clinical practice Ramsey BC (61)-Myocardial Assessment with Cardiac CT: Ischemic Heart Disease and Beyond Schuijf et al (37)-Fractional flow reserve and myocardial perfusion by computed tomography: a guide to clinical application

The role of computed tomography myocardial perfusion imaging in clinical practice(62)

SCCT expert consensus document on myocardial computed tomography perfusion imaging

The Future of Cardiovascular Computed Tomography: Advanced Analytics and Clinical Insights(64)

ACCF/AHA 2007 Clinical Competence Statement on Vascular Imaging with Computed Tomography and Magnetic Resonance Murphy et al (66) -Vascular CT and MRI

Pi Cardia and Boston Scientific. Dr. Maroules reports serving as co-founder and shareholder of Innovation Health Services/Cardioinnovations. Dr. Nagpal reports grant support from the National Institutes of Health. Dr. Steigner reports consultancy with Canon Medical (Vital Images). Dr. Wang reports consultancy with Edwards Life Sciences, Boston Scientific. She reports institutional research support from Boston Scientific (assigned to employer Henry Ford Health System) and LVOT prediction modeling software (assigned to employer Henry Ford Health System; patent). Dr. Blankstein reports research funding from

Appropriate Use Criteria 

Understand and effect minimizing acquisition field of view to reduce radiation exposure X X X Understand the concept of exposure control techniques for tube current modulation X X X Understand how ECG gating protocols effect radiation exposure X X X Understand and explain stochastic and deterministic effects of radiation exposure as it relates to CCTA X X X X X X XRecognize clinical indication-based patient specific scan protocol modifications to reduce radiation exposure without sacrificing image quality X X X X X Understand effect of pitch and slice increment on CT dose index X X * X Understand benefits and limitations radiation effective dose estimations X X * X Understand how iterative reconstruction vs filtered back projection affects image noise and may enable reduction in radiation exposure X X * X Active quality improvement in radiation dose management X * X X X X CT Fundamentals Reconstruction, Post-processing and Artifacts X Describe multiple patient preparation, protocol selection, and reconstruction/postprocessing steps that can be used to minimize patient and cardiac motion X X X Describe scanner-based and preparation-based techniques to minimize physics-based, patient-based, and scanner-based artifacts X X X Optimize image quality by performing ECG editing when needed X X X X X Demonstrate the ability to use convolution kernels and post-processing filters X X * X Demonstrate the ability to create 3D volume renderings for visualization of complex anatomy X X * X Understand the emerging role of advanced post-processing tools in CCT including machine learning, radiomics, atherosclerosis plaque quantification, coronary perivascular fat attenuation and 3D printing X * X X Coronary Anatomy and Pathology Identify coronary artery atherosclerotic disease burden X X X X Estimate coronary stenosis severity using the CAD-RADS scoring system, as well as include applicable modifiers when pertinent to standardize reporting practice X X * X X XRecognize plaque features which are associated with increased risk (i.e. plaque vulnerability) such as positive remodeling, low attenuation plaques, spotty calcification and napkin ring sign X X X Identify myocardial coronary bridging, characterize pertinent imaging and clinical features including benign prognosis X X * X Identify coronary artery dissections, aneurysm, fistulae, and anomalous origins X X X Assess coronary artery bypass graft for patency and stenosis X X X Evaluate patency of coronary stents, recognize in-stent restenosis X X X Summarize and identify coronary manifestations in connective tissue disorders, vasculitis, and fibromuscular dysplasia. X * X Structural Heart Disease Proficiency in protocoling and interpretation of retrospective-ECG gated imaging for identification of prosthetic valve dysfunction X X * X X Identify optimal fluoroscopic projections in structural heart disease procedural planning X X * TAVR: Understand indications of CCTA for pre-procedure planning of TAVR including valve sizing and vascular access planning X X * X X TAVR: Assess aortic valve calcium quantification by CCT to assist in determination of degree of valvular stenosis X X * X X TAVR: Reproducibly measure aortic annulus in the appropriate phase of the cardiac cycle to aid in TAVR device sizing and selection X X * X X TAVR: Describe how secondary measurements and landing zone calcium of the aorto-annular complex impact CT prediction of procedural risk including paravalvular leak or ventricular septal defect from infra-annular calcium or coronary obstruction by the aorto-annular complex X X * X X 

Recognize variants of anomalous coronary artery origins, courses, aneurysms, and fistulas X X * X X Recognize congenital abnormalities of pulmonary and systemic venous drainage X X * X X Demonstrate the ability to recognize pathologic vascular rings and spatial relationship of aorta and pulmonary arteries to the trachea and esophagus X X * X X Understand the unique challenges in the pediatric population including the use of sedation and optimal heart rate control for better image quality and radiation reduction techniques X X * X X Apply CHD knowledge in the planning of catheter or surgical procedures for palliation or repair of CHD X * X xUnderstand the role of CCT in neonate or young patients with complex anatomy, particularly if at higher risk for an adverse event with sedation or anesthesia required for CMR X * X xFunctional Testing for Coronary Artery Disease Understand the comparative effectiveness of CCT vs stress testing for guiding patient management X X * X X X Recognize CCT findings which may impact coronary revascularization decisions (e.g. high risk anatomy) X X * X X Describe the basic principles, strengths, limitations, and clinical trial data supporting stress CT-Perfusion (CTP) X X * X Describe the basic principles, strengths, limitations, and clinical trial data for Fractional Flow Reserve (FFR-CT) methods X X * X Recognize prior myocardial infarction and understand how to adjust scan data including window width and level to evaluate for resting perfusion abnormalities X X * X Understand the technical protocol, requirements and application of static and dynamic CTP for functional assessment of coronary artery disease X * X X X Understand the technical protocol, requirements and application FFR-CT for functional assessment of coronary artery disease X * X X XRecognize strengths/limitations of other novel CCT methods for ischemia/infarction evaluation such as late contrast enhancement