Competency Requirements
Cardiovascular disease fellowship requirements are defined by ACGME minimum training requirements and the ACC COCATS competency framework.
- ACGME — Minimum requirements for completion of cardiovascular disease fellowship
- Level I — Core training expected of cardiovascular fellows
- Level II — Additional training for independent performance or interpretation
- Advanced training — Expertise beyond routine independent practice
Note
Case numbers represent minimum experience targets. Procedural volume alone does not establish competency.
ACGME Core Requirements¶
| Training Area | Minimum |
|---|---|
| Total clinical experience | 24 months |
| Cardiac catheterization | 3 months |
| Echocardiography | 3 months |
| Nuclear cardiology, Cardiac CT, and Cardiac MRI | 3 months combined |
| Electrophysiology | 2 months |
| Non-laboratory clinical practice | 9 months |
Advocate Health Example Curriculum
ACGME Procedural Requirements¶
| Procedure / Study | Minimum |
|---|---|
| Echocardiograms performed | 75 |
| Echocardiograms interpreted | 150 |
| Diagnostic cardiac catheterizations | 100 |
| Radionuclide studies interpreted | 100 |
| Exercise stress ECG tests | 50 |
| ECGs interpreted | 3,500 |
| Direct-current cardioversions | 10 |
Echocardiography¶
ACGME: 3 months; 75 echocardiograms performed and 150 interpreted.
| Requirement | Level I | Level II |
|---|---|---|
| Training | 3 months | 6 months cumulative |
| TTE performed | 75 | 150 |
| TTE interpreted | 150 | 300 |
| Independent TTE interpretation | No | Yes |
Special Procedures¶
Transesophageal Echocardiography
- 25 esophageal intubations
- 50 supervised complete multiplanar TEE studies
- Additional 50 supervised studies recommended for broader experience
Stress Echocardiography
- 100 supervised stress echocardiograms for independent supervision and interpretation
- Should include exercise and pharmacologic stress testing
Intraoperative TEE
- Level II echocardiography and routine TEE competency first
- 100 additional supervised intraoperative TEE studies
Nuclear Cardiology¶
ACGME: Exposure within the 3-month cardiac imaging requirement and at least 100 radionuclide studies interpreted.
| Requirement | Level I | Level II |
|---|---|---|
| Training | 2 months | ≥4 months |
| Studies interpreted | 100 | 300 |
| Hands-on studies | — | 30 |
| Nuclear cardiology experience | — | 700 hours |
Level II Specifics¶
- 300 studies interpreted under supervision
- 30 hands-on studies:
- 25 myocardial perfusion studies
- 5 radionuclide angiography studies
- 30 studies correlated with invasive coronary angiography or coronary CT angiography
- 80 hours of classroom/laboratory radiation safety education
- 620 hours of supervised clinical nuclear cardiology experience
Cardiac PET
- At least 40 direct patient PET studies when pursuing Level II PET competency
Cardiac CT¶
ACGME: Cardiac CT must be included within the 3-month cardiac imaging experience. ACGME does not specify a separate CT case minimum.
| Requirement | Level I | Level II |
|---|---|---|
| Training | ~1 month | ~2 months cumulative |
| Studies interpreted | 50 | 250 |
| Present during acquisition | 15 | 65 |
| Independent interpretation | No | Yes |
Level II Specifics¶
Of the cumulative 250 cases:
- 150 cases with interactive manipulation on a 3D workstation
- 20 cases evaluating cardiac function
- 20 structural and/or congenital heart disease cases
- 15 bypass graft cases
- 40 cases correlated with invasive angiography and/or myocardial perfusion imaging
- 50 cases with active involvement in acquisition, interpretation, and reporting
Cardiac MRI¶
ACGME: Cardiac MRI must be included within the 3-month cardiac imaging experience. ACGME does not specify a separate CMR case minimum.
| Requirement | Level I | Level II |
|---|---|---|
| Training | ≥1 month | ≥3 months |
| CMR examinations | 25 | 150 |
| Scanner-based primary studies | — | 50 |
| Independent interpretation | No | Yes |
Level II Specifics¶
At least 50 examinations should involve the trainee:
- Present during scanning
- Directing image acquisition
- Participating in protocol selection
- Serving as the primary interpreter
Training should include:
- CMR physics
- Cine imaging
- Ventricular function
- Flow imaging
- Late gadolinium enhancement
- Tissue characterization
- Stress perfusion
- Cardiomyopathies
- Ischemic heart disease
- Valvular disease
- Congenital heart disease
- Pericardial disease
- Artifacts and safety
Diagnostic Cardiac Catheterization¶
ACGME: 3 months in the catheterization laboratory and at least 100 catheterizations.
| Requirement | Level I | Level II |
|---|---|---|
| Training | ~4 months | ~6 months |
| Diagnostic catheterizations | 100 | ~300 |
| Independent diagnostic catheterization | Limited | Yes |
Level I Case Mix¶
Of the 100 diagnostic catheterizations:
- At least 50 should involve coronary angiography
- At least 25 should involve hemodynamic assessment of:
- Valvular disease
- Myocardial disease
- Pericardial disease
- Congenital heart disease
Training should include:
- Arterial and venous access
- Right-heart catheterization
- Pressure waveform interpretation
- Cardiac output measurement
- Shunt assessment
- Valve hemodynamics
- Coronary anatomy and angiography
- Recognition and management of complications
Level II¶
Level II training generally includes:
- ~6 months cumulative catheterization laboratory experience
- ~300 diagnostic cardiac catheterizations
- Greater independence with invasive hemodynamics and diagnostic procedures
Level II is intended for fellows who plan to practice diagnostic invasive cardiology or proceed to interventional cardiology training.
Quick Reference¶
| Modality | Level I | Level II |
|---|---|---|
| Echo | 3 mo · 75 performed · 150 interpreted | 6 mo · 150 performed · 300 interpreted |
| Nuclear | 2 mo · 100 studies | ≥4 mo · 300 studies · 700 hr |
| Cardiac CT | ~1 mo · 50 studies · 15 acquisitions | ~2 mo · 250 studies · 65 acquisitions |
| Cardiac MRI | ≥1 mo · 25 studies | ≥3 mo · 150 studies · 50 scanner-based |
| Diagnostic Cath | ~4 mo · 100 cases | ~6 mo · ~300 cases |
ACGME vs COCATS¶
Important
ACGME and COCATS requirements are not identical.
ACGME establishes the minimum requirements necessary for an accredited cardiovascular disease fellowship.
COCATS provides more detailed training targets for achieving competency within individual cardiovascular subspecialties.
Hospital credentialing, laboratory accreditation, and certification boards may have additional requirements.
Advanced Cardiovascular Imaging¶
COCATS 4 describes Level I and Level II training within individual imaging modalities.
For advanced cardiovascular imaging training beyond Level II, refer to the 2025 ACC/AHA/ASE/ASNC/SCCT/SCMR Advanced Training Statement on Advanced Cardiovascular Imaging.
Advanced imaging training may include expertise in:
- Echocardiography
- Cardiac CT
- Cardiac MRI
- Nuclear cardiology
- Multimodality image integration
- Laboratory operations and quality improvement
- Education and research