1258

JACC Vol.n. No. sApdl 19981258-61

ACP/ACC/AHA TASK FORCE STATEMENT

Clinical Competence in Invasive Cardiac Electrophysiological Studies

ACP/ACC/AHA Task Force on Clinical Privileges in Cardiology

LEAD AUTHOR

MASOOD AKHTAR, MD. FACC

TASK FORCE MEMBERS

SANKEYV. WILLIAMS. M D. FACP, ChairnmnJAMES L . ACHORD, MD, FACP

FRANCIS J. KLOCKE, MD, FACCWILLIAM A. REYNOLDS, MD, FACP

THOMAS 1. RYAN, MD, FACCCHARLES FISCH, MD, FACC

ROBERT C. SCHLANT, MD, FACCGOTTLIEB C. FRIESINGER II . M D. FACC

no grantingofclinicalstaffprivilegestophysiciansisoneofthe primary mechanisms used by brotitutions to uphold thequality of care. The Joint Commission on Accreditation ofHealthcare Organizations requires that the granting of initialor continuing medical staff privileges be based on assess-ments of applicants against professional criteria that arespecified in the medical staff bylaws . Physicians themselvesare thus charged with identifying the criteria that constituteprofessional competence and with evaluating their peersaccordingly. Yet the process of evaluating a physician'sknowledge and co npetance is often constrained by theevaluator's own knowledge and ability to elicit the appropri-ate information, problems that are compounded by thegrowing number of highly specialized procedures for whichprivileges arc requested .

This recommendation is one in a series developed by theAmerican College of Physicians, the American College ofCardiology, and the American Heart Association to assist inthe assessment of physician competence on a procedure-specific basis. The minimum education, training, experience,and cognitive and technical skills necessary for the compe-tent performance of invasive cardiac alectrophysiobgicalstudies (BPS) are specified . Whenever possible, these spec-ifications arc based on published data linking these factorswith competence or, in the absence of such data, on the

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consensus of expert opinion. They arc applicable to anypractice setting and can accommodate a number of waysphysicians might substantiate competence in the perfoo-mance of specific procedures (see also Guide to the Use ofACP Statements on Clinical Competence (Ann Intern Med1987:107 :588-589). The recommendations listed here areonly for routine invasive electrophysiologicd studies and donet address the training and expertise needed for compe-tence in Intraoperative tachycardia mapping, evaluation ofansteehycardla devices, or catheter ablative procedures fttachycasdia control. Credentials committees of individualhspilals may need to develop their own criteria in consul-tation with appropriate experts for anthoriging the sere ofthese and other am procedures .

Overview of the ProcedureThe initial His bundle recording was m ported In 1969 bySchrlag at al (1) . Its value as a useful tool for assessing thesite of drioventricular (AV) delay and block as well as fordetermining the origin of premature bats and taehycardiaswas quickly established . At about the same time, pro-gmmmed electrical stimulation was used to initiate su-ptaventrieular tachycmdia (SVT) in patients without ventricular pscoxcitation (2). Later, induction of SVT was alsodemonstrated in WoW Parkinsot-White syndrome (3). Theability to record intmcardiac a ectrica signals from varioussides and reproduce clinical tachycardias as well as sinus andAV conduction abnormalities made invasive EPS clinicallyusefid. Due to the episodic and hence elusive nature ofcardiac arsbythmias, the techniques of invasive EPS andprogrammed electrical stimulation have become a logicalpart of the workup of patients with rhythm problems. This is

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not surprising, as sound clinical decisions can seldom bemade if the underlying arrhythmia cannot be documented . Itmay be necessary to replicate the arrhythmia if it is notdemonstrated at the time of medical evaluation .

Rationales for the recommendation of clinical electro-physiological procedures range from purely diagnostic totherapeutically curative. The value of EPS has increasedover the years and such studies are now considered useful inthe treatment of patients with a wide variety of arrhythmias .

In this report the term "EPS" refers both to the recordingof intracardiac electrical signals and programmed electricalstimulation . A detailed description of EPS is beyond thescope of this document, but the procedure is briefly outlinedbelow .

Using venous (and occasionally arterial) access, elec-hnde catheters are positioned in various intracardiac loca-tions with the help of fluoroscopy . The signals recorded viathese electrode catheters are important for precise tintingof electrical events to assess the location and direction ofimpulse propagation . The latter requires several points ofrecording to determine the activation sequence . a processfrequently called "mapping .- The usual sites of placementare the right and let atria (via coronary sinusi, His bundle,and right ventricle.

Since most arrhythmias are transient . they are unlikely tobe spontaneously present at the time of study . Programmedelectrical stimulation is needed to replicate clinical arrhyth-mies ata for conduction abnormalities as well as to induceother clinically sitWificunt abnormalities of cardiac rhythms .Once an arrhythnda Is induced electrically, reinduction canbe attempted following administration of antiarrhythmicthugs or use of other interventions (eg, Catheter ablation) todetermine ediacy of intervention. Intravenous pharemen-logic l agents both as isoproterenol, procainamide. andadenosine) ate often administered to facilitate tachytardiaInduction, unmask conduction abnormalities, or predict drugresponses.

In mho earlier days EPS primarily played a diagnostic roleand was often used to assess sinus trade function and tostudy the site of AV block (4-7) . Currently EPS is pedartaedin patients with bredycardia when there is doubt about theexact astute of the problem and whether permanent pacingIs indicated and at what mode . Early SVT studies focused oninduction, termination . mechanisms, and site of origin(2,3,8-12). Subsequently, prepmnmed electrical stimulationwas suggested as a means of gliding pharmacological thenapy in patients with inducible SYT (13) . Pharmacologicalimerventioa that tendered an inducible sustained tachycar-din to noninducibility suggested a favorable therapeuticeffect (13) . Ability to reproducibly induce clinical SVT alsofed to the introduction of various nonpharmacologial meansof achieving therapeutic control, the most recent being thecatheter ablative techniques (14-17).

The role of BPS in patients with ventricular tachycardia-ventricdar fibrillation (VT-VF) has also undergone signifi-cant evolution (I8-2A). At the present time such patients arc

ACIVACC/AHA TASK FORCECLINICAL COMPnTENCn IN INVASIVE CARDIAC RLEC[ROPHYSIOLGGY

studied to determine the exact name of wide QRS tachy-cardia, to assess the efficacy of pharmacological therapy,and to select patients for nonpharmacological treatmentssuch as VT surgery, catheter ablation. and implantablecardioverter defibrillator and antitachycardia devices, in-cluding those with backup defibrillation capabilities . EPSwill probably be used increasingly for the assessment of riskof serious arrhythmic events and hence as a method for riskstratification (25 .26).

Physicians involved in perforating invasive EPS shouldbe aware of its Indications, contrtdndications, and complica-tions to properly assess the risks and benefits of EPS in agiven patient (27-29) . The absolute contraindicadDru; are fewand include situations such as critical disease of the left maincoronary artery. unstable angina . bactercmialsepticcmia .fulminam congestive heart failure (not caused by arrhyth-mias) . major bleeding diathesis . and deep vein thrombosis iffemoral vein tannulalian is desired. However, the physicianshould also use extreme caution in clinical settings in whichthe patient is not considered stable (eg, hemodynamic insta-bility . electrolyte acid-base imbalance) or is otherwise en-able to toterase the procedure .

In the vast majority of situations, EPS is performed on anelective basis, usually for chronic problems . Risks can behigh when EPS and/or programmed electrical stimulation areperformed on an argent basis. ad such risks are justifiableonly if the arrhythmia is the malt+ or the major cause of theemergency, as in incessant VT .

The complete list of indications is detailed in the ACC/AHA task force document on guidelines for clinical intra-cardiac EPS (29).

Justlficntion for Recommendations

The indications, comraindicatiots, and recommendationsfoe the minimum education, training, experience, and skillsnecessary to perform EPS are principally derived from theopinion of the ACPJACC!AHA Task Force on Cardiology ofthe Anteticas College of Physicians' Clinical PrivilegesProject .

Expertise in invasive BPS requires not only the ability tosafely perform the cardiac catheteriIeation necessary forintracardiac recording and cardiac stimulation but also athorough understanding for correct interpretation of gath-ered data. The letter in particular requires an ongoing effortto stay abreast in this rapidly evolving field . Such effort isessential for accurate diagnosis and prognostication as wellas application of state-af-the art therapy . As knowledge hasincreased . the interpretation of data acquired in the electro-physiology laboratory has become increasingly complex .The quality of diagnostic information forms the basis for agiven therapeutic approach . The gathering of interpretabledata is particularly critical in the selection of nonpharmaco-logical therapy, a practice that seems to be gaining wideracceptance in patients with both SVT and VT . It therefore

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ACPrACC!AHA TASK FORCE

1261CLINICAL COMPETENCE IN INVASIVE CARDIAC ELECTROPHYSIOLOGYApril 1994,1259-61

Maintenance of CompetenceLike many other procedures, a minimum number of cases isnecessary to ensure quality of care. This is a _ritical issueboth for the institution and the operator. The individualshould perform at least 100 procedures per year to maintainskills and should attend at least 30 hours offormal continuingmedical education (level I category) instruction every 2years to remain abreast of changes in technologies andknowledge.

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