EAPC core curriculum for preventive cardiology

EAPC Co e Cu iculum o P e en i e Ca diology Ma hias Wilhelm 1 *, Ana Ab eu 2 , Paolo Emilio Adami 3 , Ma co Amb ose i 4 , Ma ia An onopoulou 5 , Alessand o Bi i 7 , Elena Ca a e a 8,9 , Fla io D’Ascenzi 6 , I ene Gibson 10 , Diede ick E. G obbee 11 , Ma ie-Ch is ine Iliou 12 , Kons an inos Koskinas 1 , Ped o Ma ques-Vidal 13 , Uwe Nixdo 14 , Michael Papadakis 15 , Massimo F. Piepoli 16 , Vass Vassiliou 17 ,Da idWood 18,19 , Paul Dendale 20 , and Ma in Halle 21 * 1 Depa men o Ca diology, Inselspi al, Be n Uni e si y Hospi al, Uni e si y o Be n, F eibu gs asse 46, 3010 Be n, Swi ze land; 2 Se ico de Ca dioologia, Hospi al Uni e si a io de San a Ma ia/Cen o Hospi ala Uni e si a io Lisboa No e (CHULN), Cen o Academico de Medicina de Lisboa (CAML), Cen o Ca dio ascula da Uni e sidade de Lisboa (CCUL), A enida P o esso Egas Moniz, 1649-035 Lisbon, Po ugal; 3 Heal h and Science Depa men , Wo ld A hle ics, Monaco P incipali y, 6-8 Quai An oine 1e , 98007 Monaco, Monaco; 4 Ca diac Rehabili a ion Uni , ASST, Via Medaglie D’O o, 9, 26013 C ema, I aly; 5 Spili P ima y Ca e Cen e, Regional Heal h Sys em o C e e, 740 53 Spili, G eece; 6 Depa men o Medical Bio echnologies, Di ision o Ca diology, Uni e si y o Siena, Viale Ma io B acci 16, 53100 Siena, I aly; 7 Med-Ex Medicine & Exe cise, Medical Pa ne Scude ia Fe a i, Via Vi o io Vene o 108, 00187 Rome, I aly; 8 Depa men o Medical-Su gical Sciences and Bio echnologies, Sapienza Uni e si y o Rome, Co so della Repubblica 97, 04100 La ina, I aly; 9 Medi e anea Ca diocen o, Via O azio, 2, 80122 Naples, I aly; 10 Na ional Ins i u e o P e en ion and Ca dio ascula Heal h, Moyola Lane, Newcas le, Galway H91 FF68, I eland; 11 Julius Cen e o Heal h Sciences and P ima y Ca e, and Uni e si y Medical Cen e U ech , 3584 CX U ech, The Ne he lands; 12 Ca diac Rehabili a ion and Seconda y P e en ion Depa men , Co en in Cel on Hospi al, Assis ance Publique Hopi aux de Pa is Cen e Uni e si e´ de Pa is, Pa is Co en in Cel on 4, 92130 Issy-les-Moulineaux, Pa is, F ance; 13 Depa men o Medicine, In e nal Medicine, Lausanne Uni e si y Hospi al (CHUV), Rue du Bugnon 46, 1011 Lausanne, Swi ze land; 14 Eu opean P e en ion Cen e c/o Medical Cen e Du¨sseldo , Luise-Raine -S aße 6-10, 40235 Du¨sseldo , Ge many; 15 Ca dio ascula Clinical Academic G oup, S Geo ge’s, Uni e si y o London, London SW17 0RE, UK; 16 Ca diac Uni , Guglielmo da Salice o Hospi al, Uni e si y o Pa ma, 29121 Piacenza, I aly; 17 Depa men o Ca dio ascula Medicine, Uni e si y o Eas Anglia, No wich Resea ch Pa k, No wich NR4 7TJ, UK; 18 Na ional Ins i u e o P e en ion and Ca dio ascula Heal h, Na ional Uni e si y o I eland Galway, Uni e si y Road, Galway H91 TK33, I eland; 19 Na ional Hea and Lung Ins i u e, Impe ial College London, London SW3 6LY, UK; 20 Hea Cen e Hassel and Hassel Uni e si y, 3500 Hassel , Belgium; and 21 Depa men o P e en ion and Spo s Medicine, Uni e si y Hospi al ech s de Isa , Technical Uni e si y Munich, Ge man Cen e o Ca dio ascula Resea ch, Geo g-B auchle-Ring 56, 80992 Munich, Ge many Recei ed 5 No embe 2020; e ised 15 Janua y 2021; accep ed 19 Janua y 2021 * Co esponding au ho s. Tel: þ41 31 632 8986, Email: ma [email protected] (M.W.); Tel: þ49 89 289 244 31, Email: [email p o ec ed] (M.H.) EAPC Co e Cu iculum Task Fo ce: Chai : Ma hias Wilhelm Ana Ab eu, Paolo Emilio Adami, Alessand o Bi i, Elena Ca a e a, Fla io D’Ascenzi, Paul Dendale, I ene Gibson, Diede ick E. G obbee, Ma in Halle, Kons an inos Koskinas, Uwe Nixdo , Michael Papadakis, Massimo Piepoli, Vass Vassiliou, Da id Wood EAPC Co e Cu iculum W i ing G oup: Popula ion Science and Public Heal h Sec ion: Kons an inos Koskinas, Ped o Ma ques-Vidal, Vass Vassiliou P ima y Ca e and Risk Fac o Managemen Sec ion: Ma ia An onopoulou, Alessand o Bi i, I ene Gibson Seconda y P e en ion and Rehabili a ion Sec ion: Ana Ab eu, Ma co Amb ose i, Ma ie-Ch is ine Iliou Spo s Ca diology and Exe cise Sec ion: Paolo Emilio Adami, Elena Ca a e a, Michael Papadakis Young Communi y: Fla io D’Ascenzi EAPC Boa d Re iewe s: Sil ia Cas elle i, Emeline Van C aenenb oeck, Cons an in Da os, Nicolle K aenkel, T ine Mohold , Jose Niebaue ESC Educa ion Commi ee Re iewe s: Nick B ooks, Agne`s Pasque , Felix Tanne V CThe Au ho (s) 2021. Published by Ox o d Uni e si y P ess on behal o he Eu opean Socie y o Ca diology. This is an Open Access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion Non-Comme cial License (h p://c ea i ecommons.o g/licenses/by-nc/4.0/), which pe mi s non-comme cial e-use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed. Fo comme cial e-use, please con ac jou nals.pe [email protected] Eu opean Jou nal o P e en i e Ca diology POSITION PAPER doi:10.1093/eu jpc/zwab017 Downloaded om h ps://academic.oup.com/eu jpc/ad ance-a icle/doi/10.1093/eu jpc/zwab017/6207430 by Uni e sidade de Lisboa use on 22 Ap il 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P e en i e ca diology encompasses he whole spec um o ca dio ascula disease (CVD) p e en ion, a indi idual and popula ion le el, h ough all s ages o li e. This includes p omo ion o ca dio ascula (CV) heal h, managemen o indi iduals a isk o de eloping CVD, and managemen o pa ien s wi h es ablished CVD, h ough in e disciplina y ca e in di e en se ings. P e en i e ca diology add esses all aspec s o CV heal h in he con ex o he social de e minan s o heal h, including physical ac i i y, exe cise, spo s, nu i ion, weigh managemen , smoking cessa ion, psychosocial ac o s and beha iou al change, en i onmen al, gene ic and biological isk ac o s, and CV p o ec i e medica ions. This is he i s Eu opean Co e Cu iculum o P e en i e Ca diology, which will help o s anda dize, s uc u e, deli e , and e alua e ain- ing in p e en i e ca diology ac oss Eu ope. I will be he basis o dedica ed ellowship p og ammes and a Eu opean Socie y o P e en i e Ca diology (EAPC) subspecial y ce i ica ion o ca diologis s, wi h he in en ion o imp o e quali y and ou come in CVD p e en ion. ............................ ............. ............. .................. ............. ............. ............................... ............. ............. .................. ............. ......... Keywo ds Popula ion science •P e en ion o CVD •Ca dio ascula ehabili a ion •Spo s ca diology •Exe cise es ing Table o con en Lis o abb e ia ions............................................. 3 De ini iono p e en i eca diology............................... 3 P e en i e ca diology– owa ds a sub-special y o ca diology . . . . . . 3 The concep o he co e cu iculum o p e en i e ca diology. . . . . 4 1.CanMEDS oles .......................................... 7 2.Clinicalcompe encies..................................... 7 3.En us ablep o essionalac i i ies.......................... 7 4.Le elo independence.................................... 8 5.Assessmen o clinicalcompe encesusingEPAs............ 9 Sou ceso knowledgeinp e en i eca diology................... 9 Chap e 1:Popula ionscienceandpublicheal h.................. 9 1.1 Design, implemen and e alua e p e en i e in e en ions a he popula ionle el........................................... 9 Chap e 2: P ima y p e en ion and isk ac o managemen . . . . . . 10 2.1 Manage indi iduals wi h mul i ac o ial ca dio ascula isk p o iles................................................. 10 2.2 Manage a pa ien wi h non- adi ional ca dio ascula isk ac o s.................................................. 11 Chap e 3:Seconda yp e en ionand ehabili a ion.............. 12 3.1 Manage a p e en ion and ehabili a ion p og amme o a ca - dio ascula pa ien ....................................... 12 3.2 Manage a p e en ion and ehabili a ion p og amme o a ca - dio ascula pa ien wi h signi ican como bidi ies, ail y, and/o ca diacde ices........................................... 14 3.3 Manage a ca dio ascula p e en ion and ehabili a ion p o- g amme o anoncologypa ien .......................... 16 Chap e 4:Spo sca diologyandexe cise....................... 17 4.1 Manage p e-pa icipa ion sc eening in a compe i i e a hle e 17 4.2 Manage he wo k-up o an a hle e wi h suspec ed o known ca dio ascula disease.................................... 19 Chap e 5:Ca diopulmona yexe cise es ing.................... 20 5.1 Use ca diopulmona y exe cise es ing o diagnosis, isk s a i i- ca ionandexe cisep esc ip ion.......................... 20 Lis o abb e ia ions 6MWT 6-min walk es AHA Ame ican Hea Associa ion ACC Ame ican College o Ca diology CIED Ca diac implan able elec ical de ices CVD Ca dio ascula disease CV Ca dio ascula CPET Ca diopulmona y exe cise es ing DOPS Di ec obse a ion o p ocedu al skills EAPC Eu opean Associa ion o P e en i e Ca diology EBSC Eu opean Boa d o he Special y o Ca diology ECG Elec oca diog am EPA En us able p o essional ac i i y ESC Eu opean Socie y o Ca diology LVAD Le en icula assis de ice Mini-CEX Mini clinical e alua ion exe cise MCQ Mul iple choice ques ion PPE P e-pa icipa ion e alua ion De ini ion o p e en i e ca diology P e en i e ca diology encompasses he whole spec um o ca dio- ascula disease (CVD) p e en ion, a indi idual and popula ion le el, h ough all s ages o li e. This includes p omo ion o ca dio ascula (CV) heal h, manage- men o indi iduals a isk o de eloping CVD, and managemen o pa ien s wi h es ablished CVD, h ough in e disciplina y ca e in di - e en se ings. P e en i e ca diology add esses all aspec s o CV heal h in he con ex o he social de e minan s o heal h, including physical ac i i y, exe cise, spo s, nu i ion, weigh managemen , smoking ces- sa ion, psychosocial ac o s and beha iou al change, en i onmen al, gene ic and biological isk ac o s, and CV p o ec i e medica ions. P e en i e ca diology— owa ds a sub-special y o ca diology Scien i ic ad ances ha e led o a subs an ial decline o dea h om CVD o e he las decades. 1 Howe e , CVD mo bidi y emains high and CVD a e s ill he mos common cause o dea h ac oss Eu opean Socie yo Ca diology(ESC)membe coun ies. 2 While posi i e ends ha e been obse ed o medical managemen o a e ial hype ension and dyslipidaemias, he p e alence o obesi y has mo e han doubled and he p e alence o diabe es melli us has ipled in Eu ope. 2 Mo e ecen declines in he age-s anda dized incidence o CVD ac oss ESC membe coun ies ha e been small o absen . 2 The incidence o CVD’s majo componen s, ischaemic hea disease, and s oke, ha e bo h shown a downwa d end bu changes in p e alence ha e been small. 2 In a Eu opean Hea Ne wo k s udy, CVD was es ima ed o 2M. Wilhelm e al. Downloaded om h ps://academic.oup.com/eu jpc/ad ance-a icle/doi/10.1093/eu jpc/zwab017/6207430 by Uni e sidade de Lisboa use on 22 Ap il 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . cos he Eu opean Union economy 210 billion Eu o a yea in 2015, o which 53% (111 billion Eu o) was due o heal hca e cos s. 2 The ca diology communi y has s a ed a ansi ion om p edomin- an ly ea men o p e en ion o CVD. 3 A la ge body o scien i ic e i- dence has been gene a ed and app op ia e guidelines and posi ion pape s a e a ailable in he ou domains o p e en i e ca diology: Popula ion science and public heal h, 4,5 p ima y p e en ion and isk ac o managemen , 3,6–8 seconda y p e en ion and ca dio ascula e- habili a ion, 3,9–14 and spo s ca diology and exe cise. 15–21 The Eu opean Associa ion o P e en i e Ca diology (EAPC) has ecen ly s a ed cen e acc edi a ion in hese domains o s anda dize and op- imize ca e. 22 His o ically, CV p e en ion has been classi ied in o p imo dial p e- en ion (popula ion-based measu es o p e en isk ac o de elop- men ), p ima y p e en ion (managemen o indi iduals wi hou clinically mani es disease bu a isk o de eloping CVD, wi h he aim o delaying o p e en ing he onse o disease), and seconda y p e en ion ( ocusing on people wi h es ablished CVD). While p e en i e measu es indeed di e in a ious ways o hese h ee ca ego ies, his Task Fo ce also acknowledges ha CV isk is a con inuum and ha se e al meas- u es o enhance CV heal h a e applicable ac oss he spec um o CV p e en ion. Mo eo e , he dis inc ion be ween p ima y and seconda y p e en ion, albei well-es ablished, may in ce ain occasions be a i icial; while people wi h subclinical disease (e.g. e idence o ad anced a he o- scle osis by imaging, bu no ye wi h clinically mani es CVD) would o mally belong o ‘p ima y p e en ion’, hey o en quali y o in e en- ions applicable o he ‘seconda y p e en ion’ se ing. Bo h in high-, middle-, and low-income coun ies, nine po en ially modi iable heal h beha iou s and CV isk ac o s accoun o mos o he popula ion a ibu able isk o myoca dial in a c ion and s oke in bo h sexes and a all ages. 23,24 Smoking, physical inac i i y, unheal hy nu i ion pa e ns, obesi y, psychosocial ac o s, diabe es melli us, dyslipidaemias, and a e ial hype ension a e key a ge s o li es yle in e en ions, and op imiza ion o medical he apy. In addi ion, bioma ke s and gene ics isk sco es 25 ha e he po en ial o u he cha ac e ize indi idual CVD isk p o iles. Beyond adi ional isk ac o s, o he d i e s o esidual CV isk ha e come o he o e on , including in lamma o y, p o- h ombo ic, and me abolic pa hways ha con ibu e o ecu en e en s and a e o en un ecognized and no add essed in clinical p ac ice. 26 The inc easing a es o obesi y and diabe es, he subop imal li e- s yle managemen and implemen a ion o guideline-di ec ed medical he apy in seconda y p e en ion o CVD, 27 and he gaps in e idence highligh he need o u he in es men in p e en i e ca diology. The le el o p o ound knowledge, specialized skills, and commi ed a i udes goes beyond co e ca diology aining and jus i ies sub- special y aining. In addi ion o expe ise in a single CVD isk ac o (e.g. diagnosis and managemen o dyslipidaemias), compe encies a e equi ed o e alua e and manage single isk ac o s in he indi idual’s o e all isk p o ile, ake en i onmen al, gene ic, li es yle and psycho- social aspec s in o accoun , in eg a e guideline-di ec ed medical he - apy, and p opose a holis ic managemen plan including a ainable and ealis ic sho -, mid-, and long- e m goals. Mo i a ional in e iewing skills a e equi ed o gain he pa ien ’s willingness o adhe e o li e- s yle changes and guideline-di ec ed medical he apies in o de o each hese goals. Leade ship and communica ion skills a e equi ed o coope a e wi h in e disciplina y heal hca e eams and o he pa ne s. Beside classical pa ien g oups (indi iduals wi h CV isk ac- o s, pa ien s a e acu e co ona y synd omes, o wi h ch onic co - ona y synd omes, hea ailu e, implan able de ices, pe iphe al a e y disease), p e en i e ca diology can con ibu e o CV isk ac o man- agemen in di e en pa ien popula ions, e.g. diabe es, 6 a ial ib illa- ion, 28 and cance . 29,30 Mo eo e , speci ic aspec s o spo s ca diology will ha e o be co e ed (Figu e 1). As a sub-special y, a b oade pe spec i e o CVD p e en ion is ne- cessa y. P egnancy, in ancy, adolescence, ea ly adul hood, adul and elde ly li e a e dis inc pe iods wi h indi idual po en ial oppo uni ies o p e en ion. P e-concep ion and p egnancy a e impo an phases o he nex gene a ion, while pos -mo em au opsy may e eal ele- an in o ma ion o li ing ela i es (Figu e 2). 31 P ecision medicine and digi al heal h s a o play a ole in CVD p e en ion and ha e he po en ial o imp o e pheno yping o pa ien s o mo e pe sonalized and ailo ed he apies, and be e ou comes. 32,33 Eme ging concep s in o m new collabo a ions in he u u e and an expansion o he ield o p e en i e ca diology. A common Eu opean co e cu iculum o p e en i e ca diology will help o s anda dize, s uc u e, deli e , and e alua e aining o ca diologis s in p e en i e ca diology ac oss Eu ope. This will be he basis o dedica ed ellowship p og ammes and an EAPC sub- special y ce i ica ion, con ibu ing o imp o emen s o quali y and ou come in CVD p e en ion. Simila ini ia i es ha e been launched in he USA. 34–36 In he e ol ing ield o p e en i e ca diology, he co e cu iculum will ha e o be upda ed a egula in e als o include eme ging concep s and new scien i ic e idence. The concep o he co e cu iculum o p e en i e ca diology The changing na u e o ou p o ession and he changing en i onmen o heal hca e has led o speci ic equi emen s in he ield o ca di- ology. In 2007, he Eu opean Boa d o he Special y o Ca diology (EBSC) published ecommenda ions o sub-special y acc edi a ion in ca diology. 37 A sub-special y is de ined as a speci ic ield o ca di- ology, whe e knowledge and skills go beyond he basic equi emen s o gene al ca diology and addi ional aining is necessa y. Sub- special y aining should be based on a published co e cu iculum. 37 The co e cu iculum should include a o mal educa ion plan in ended o b ing expec ed lea ning ou comes. I should include he a ionale, aims, and objec i es, expec ed lea ning ou comes, educa ion con en , eaching and lea ning s a egies, and assessmen p ocedu es. 37 O e he las decades, sub-special y cu icula ha e been de el- oped and published by mos ESC associa ions (Acu e Ca dio ascula Ca e, A hy hmias & Ca diac Pacing, Hea Failu e, Ca dio ascula Imaging, Pe cu aneous Ca dio ascula In e en ions). 38 In he ield o p e en i e ca diology, he Ame ican College o Ca diology (ACC)/ Ame ican Hea Associa ion (AHA) published a compe ence and aining s a emen in 2009. 34 Mo e ecen p oposals o spo s ca di- ology quali ica ion a e a ailable om he ACC and EAPC. 16,39 This documen is he i s common Eu opean co e cu iculum o p e en i e ca diology, co e ing all aspec s o he ield, including p e- en ion, ehabili a ion, and spo s ca diology. I should se e as a amewo k o he sub-special y quali ica ion o ca diologis s in ESC Co e Cu iculum o P e en i e Ca diology 3 Downloaded om h ps://academic.oup.com/eu jpc/ad ance-a icle/doi/10.1093/eu jpc/zwab017/6207430 by Uni e sidade de Lisboa use on 22 Ap il 2021 Figu e 1 P e en i e ca diology—domains, necessa y compe encies, and coope a ion pa ne s. CPET, ca diopulmona y exe cise es ing; CV, ca dio ascula . Figu e 2 Li elong ca dio ascula disease p e en ion om he c adle o he g a e and beyond. 31 4M. Wilhelm e al. Downloaded om h ps://academic.oup.com/eu jpc/ad ance-a icle/doi/10.1093/eu jpc/zwab017/6207430 by Uni e sidade de Lisboa use on 22 Ap il 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p e en i e ca diology. The desc ip ion o p ac ical educa ional p o- g ammes, equi emen s o aining cen es and aine s is ou o he scope o his documen , and will be add essed in u u e documen s. Ad anced compe encies in spo s ca diology may be equi ed in dedi- ca ed e e al cen es, add essed by a speci ic addi ional cu iculum. A co e cu iculum ask o ce was es ablished in 2019, including mem- be s o he EAPC Educa ion Commi ee, he EAPC Boa d, and he EAPC Young Communi y. A w i ing g oup, including ep esen a i es o he ou EAPC sec ions con ibu ed o he d a ing o he en us able p o essional ac i i ies (EPAs). 40 Thei iewsandcommen swe ecap- u ed in an i e a i e p ocess employing elecon e ences, in-pe son dis- cussions, an online Delphi su ey, and wo kshops a EAPC mee ings. The documen was de eloped in coope a ion wi h he ask o ce o he ESC Co e Cu iculum o he Ca diologis . 41 Key compe en- cies om he ield o p e en i e ca diology a e impo an o co e ca diology aining and co e ed in Chap e 8 on p e en ion, ehabili- a ion, and spo s. 41 This chap e was used du ing he d a ing p o- cess o his documen , and se ed as a guideline o ha monize s uc u e and con en . The in en ion o his co e cu iculum is o de- sc ibe he addi ional knowledge, skills, and a i udes necessa y o sub-special y quali ica ion in p e en i e ca diology. The inal docu- men was app o ed by he EAPC Boa d in Oc obe 2020, and e iewed by he ESC Educa ion Commi ee. 1. CanMEDS oles The Royal College o Physicians and Su geons o Canada ha e p o- duced a widely accep ed s anda d amewo k o physician oles, CanMEDS. 42 This amewo k was buil o iden i y and desc ibe he abili ies physicians equi e o e ec i ely mee he heal hca e needs o he people hey se e (Table 1). 42 The ESC has adop ed he CanMEDS oles in he ESC Co e Cu iculum o he Ca diologis . 41 CanMEDS oles can be assessed and augh indi idually, and hey a e all ep esen ed o a di e en ex end in each o he EPAs o he Co e Cu iculum o P e en i e Ca diology as ou lined in Chap e s 1–5. While EPAs a e p oposed as he p e e ed me hod o assessing special y compe encies, he CanMEDS oles can be iewed as gene ic compe encies o physicians. In he ield o p e en i e ca diology, physicians wo k in in e discip- lina y eams and he scope o ca dio ascula p e en ion goes beyond pa ien ca e. Thus, he CanMEDs oles o communica o , collabo - a o , and heal h ad oca e a e o pa icula impo ance. 2. Clinical compe encies The concep ualiza ion, o ganiza ion, and adminis a ion o p e en i e ca diology in ol es di e en g oups o heal hca e p o essionals. In he con ex o his cu iculum, we ocus on he compe ences o he ca diologis o adminis e o p e en i e ca diology in clinical p ac ice. In addi ion o he clinical compe encies acqui ed du ing co e ca di- ology aining, 41 he sub-special y o p e en i e ca diology equi es speci ic knowledge, skills and app op ia e a i udes in p ima y p e- en ion, isk ac o assessmen and managemen , popula ion science, public heal h, seconda y p e en ion, ehabili a ion, spo s ca diology, and exe cise es ing and aining. The numbe o clinical compe encies calls o assessmen h ough- ou sub-special y aining. Wi hin he p ocess o con inuous p o es- sional de elopmen , his may encou age con inuous lea ning which will con inue a e sub-specialis ce i ica ion. To enable hese goals, he co e cu iculum consis s o EPAs (see below). To make know- ledge accessible, each EPA con ains a de ailed map linking o con em- po a y guidelines and posi ion pape s and he ESC opic lis , he eby enabling c oss-linking wi h knowledge and aining da abases includ- ing ex books, s uc u ed and case-based lea ning cou ses, cong ess p og ammes, and online ma e ials. 41 3. En us able p o essional ac i i ies T us is no only cen al o he ela ionship be ween aine s and ainees, bu also in he sha ed decision-making p ocess be ween physicians and hei pa ien s, and in he in e ac ion wi h o he heal h- ca e p o essionals. 41 An EPA is a key ask o a discipline ha an indi- idual can be us ed o pe o m in a gi en heal hca e con ex , once su icien compe ence has been demons a ed. 40 The EPA concep allows aine s o make compe ency-based decisions abou he le el o supe ision equi ed by ainees. 40 Compe ency-based educa ion a ge s s anda dized le els o p o iciency o gua an ee ha all lea n- e s ha e a su icien le el o p o iciency a he comple ion o ain- ing. 40 EPAs a e no an al e na i e o compe encies, bu a means o ansla e compe encies in o clinical p ac ice. While compe encies a e desc ip o s o physicians, EPAs a e desc ip o s o wo k. EPAs usually equi e mul iple compe encies in an in eg a i e holis ic na u e. 40 EPAs a e obse able and measu able and can be mapped o compe- encies and miles ones ac oss he en i e landscape o physician ac i - i ies. They can be moni o ed, documen ed, and ce i ied. 41 The Ame ican Boa d o Pedia ics was one o he i s ce i ying agencies ha in oduced he concep o EPAs in hei e ised aining guideline o he sub-special y o paedia ic ca diology in 2015. 43 The ESC has in oduced EPAs in he 2020 upda e o he ESC Co e Cu iculum o he Ca diologis , con aining one chap e on p e en- ion, ehabili a ion, and spo s wi h se en EPAs. 41 The nine EPAs o he EAPC Co e Cu iculum o P e en i e Ca diology desc ibe he addi ional compe encies necessa y o he sub-special y o p e en i e ca diology and a e g ouped in chap e s, acco ding o speci ic domains o p e en i e ca diology (Table 2). All EAPC sec ions we e in ol ed in he de ini ion o he con en . The EPA 2.2 Manage a pa ien wi h non- adi ional ca dio ascula isk ac- o s, builds upon he compe encies equi ed o EPA 2.1 Manage indi- iduals wi h mul i ac o ial ca dio ascula isk p o iles, and he knowledge, skills, and a i ude sec ions emphasize addi ional and pa icula ly ele- an aspec s only. The same applies o EPA 3.2 Manage a p e en ion and ehabili a ion p og amme o a ca dio ascula pa ien wi h signi ican como bidi ies, ail y, and/o ca diac de ices,andEPA3.1Manage a p e- en ion and ehabili a ion p og amme o a ca dio ascula pa ien .The EPA 5.1 Use ca diopulmona y exe cise es ing o diagnosis, isk s a i ica- ion and exe cise p esc ip ion, deals wi h a es ing modali y, speci ic o p e en i e ca diology, since independen execu ion and in e p e - a ion is no equi ed du ing co e ca diology aining. 41 This EPA is ele an in all domains o p e en i e ca diology. All EPAs o his co e cu iculum sha e a common s uc u e. The clinical compe ence is de ined in he i le, ollowed by a desc ip ion o scope and ime ame, se ing, including and excluding si ua ions and p ocedu es. Rele an oles o he CanMEDS Physician Compe ency F amewo k a e men ioned. 42 Knowledge, skills, and a i udes a e o - mula ed as lea ning ou comes, and assessmen ools a e ecom- mended. The equi ed le el o independence is men ioned. Rela ed ESC Co e Cu iculum o P e en i e Ca diology 5 Downloaded om h ps://academic.oup.com/eu jpc/ad ance-a icle/doi/10.1093/eu jpc/zwab017/6207430 by Uni e sidade de Lisboa use on 22 Ap il 2021 .................................................. .............................................................. ..................................................................... ............................... Table 1 CanMEDS Physician Compe ency F amewo k, modi ied and adop ed om he Royal College o Physicians and Su geons o Canada, wi h pe mission 42 Role Desc ip ion Key compe encies Medical expe As medical expe s, physicians in eg a e all o he CanMEDS oles, applying medical knowledge, clinical skills, and p o essional alues in hei p o ision o high quali y and sa e pa ien -cen ed ca e. Medical expe is he cen al physician ole in he CanMEDS ame- wo k and de ines he physician’s clinical scope o p ac ice. •P ac ise medicine wi hin hei de ined scope o p ac ice and expe ise •Pe o m a pa ien -cen ed clinical assessmen and es ablish a man- agemen plan •Plan and pe o m p ocedu es and he apies o he pu pose o as- sessmen and/o managemen •Es ablish plans o ongoing ca e and, when app op ia e, imely consul a ion •Ac i ely con ibu e, as an indi idual and as a membe o a eam p o- iding ca e, o he con inuous imp o emen o heal hca e quali y and pa ien sa e y •Apply no el digi al me hods o diagnosis, ea men communica ion and p ocess o achie e op imal clinical ou comes Communica o As communica o s, physicians o m ela ionships wi h pa ien s and hei amilies ha acili a e he ga he ing and sha ing o essen ial in o ma ion o e ec i e heal h ca e. •Es ablish p o essional he apeu ic ela ionships wi h pa ien s and hei amilies (in-pe son and i ual communica ion) •Elici and syn hesize accu a e and ele an in o ma ion, inco po a - ing he pe spec i es o pa ien s and hei amilies •Sha e heal hca e in o ma ion and plans wi h pa ien s and hei amilies •Engage pa ien s and hei amilies in de eloping plans ha e lec he pa ien ’s heal hca e needs and goals •Documen and sha e w i en and elec onic in o ma ion abou he medical encoun e o op imize clinical decision-making, pa ien sa e y, con iden iali y, and p i acy Collabo a o As collabo a o s, physicians wo k e ec i ely wi h o he heal hca e p o essionals o p o ide sa e, high quali y, pa ien -cen ed ca e. •Wo k e ec i ely wi h physicians and o he colleagues in he heal h- ca e p o essions •Wo k wi h physicians and o he colleagues in he heal hca e p o es- sions o p omo e unde s anding, manage di e ences, and esol e con lic s •Hand o e he ca e o a pa ien o ano he heal hca e p o essional o acili a e con inui y o sa e pa ien ca e Leade As leade s, physicians engage wi h o he s o con ibu e o a ision o a high-quali y heal hca e sys em and ake esponsibili y o he deli e y o excellen pa ien ca e h ough hei ac i i ies as clinicians, adminis a- o s, schola s, o eache s •Con ibu e o he imp o emen o heal hca e deli e y in eams, o ganiza ions, and sys ems •Engage in he s ewa dship o heal hca e esou ces •Demons a e leade ship in p o essional p ac ice •Manage ca ee planning, inances, and heal h human esou ces in a p ac ice Heal h ad oca e As heal h ad oca es, physicians con ibu e hei expe - ise and in luence as hey wo k wi h communi ies o pa ien popula ions o imp o e heal h. They wo k wi h hose hey se e o de e mine and unde s and needs, speak on behal o o he s when equi ed, and suppo he mobiliza ion o esou ces o e ec change. •Respond o an indi idual pa ien ’s heal h needs by ad oca ing wi h he pa ien wi hin and beyond he clinical en i onmen •Respond o he needs o he communi ies o popula ions hey se e by ad oca ing wi h hem o sys em-le el change in a socially ac- coun able manne Schola As schola s, physicians demons a e a li elong commi - men o excellence in p ac ice h ough con inuous lea ning and by eaching o he s, e alua ing e idence, and con ibu ing o schola ship. •Engage in he con inuous enhancemen o hei p o essional ac i - i ies h ough ongoing lea ning •Teach s uden s, esiden s, he public, and o he heal h ca e p o essionals •In eg a e bes a ailable e idence in o p ac ice Con inued 6M. Wilhelm e al. Downloaded om h ps://academic.oup.com/eu jpc/ad ance-a icle/doi/10.1093/eu jpc/zwab017/6207430 by Uni e sidade de Lisboa use on 22 Ap il 2021 . . . . . . . . . . . . . . . . . . . . . . . . ESC Guidelines and EAPC Posi ion Pape s a e included as p ima y sou ces o knowledge. Rele an opics om he ESC opic lis o each EPA a e summa ized in a Supplemen a y ma e ial online,File. 4. Le el o independence The le el o en us men o independence o execu ing an EPA will change du ing he aining pe iod (Table 3). A a ce ain ime o he aining, ainees may ha e di e en le els o independence in di e - en EPAs. 41 Gi en he b oad spec um o CVD p e en ion, sub- special y aining is no in ended o achie e le el o independence o i e in all nine EPAs. Fo he ollowing h ee EPAs, a lowe le el o in- dependence is ecommended. 1.1 Design, implemen and e alua e p e en i e in e en ions a he popula ion le el (le el 3) .................................................. .............................................................. ..................................................................... ............................... Table 1 Con inued Role Desc ip ion Key compe encies •Con ibu e o he c ea ion and dissemina ion o knowledge and p ac ices applicable o heal h P o essional As p o essionals, physicians a e commi ed o he heal h and well-being o indi idual pa ien s and socie y h ough e hical p ac ice, high pe sonal s anda ds o beha iou , accoun abili y o he p o ession and soci- e y, physician-led egula ion, and main enance o pe - sonal heal h. •Demons a e a commi men o pa ien s by applying bes p ac ices and adhe ing o high e hical s anda ds •Demons a e a commi men o socie y by ecognizing and espond- ing o socie al expec a ions in heal h ca e •Demons a e a commi men o he p o ession by adhe ing o s and- a ds and pa icipa ing in physician-led egula ion •Demons a e a commi men o physician heal h and well-being o os e op imal pa ien ca e .................................................. .............................................................. ..................................................................... ............................... Table 2 Compa ison o En us able P o essional Ac i i ies be ween he 2020 ESC Co e Cu iculum o he Ca diologis and he 2021 EAPC Co e Cu iculum o P e en i e Ca diology P e en i e ca diology domains ESC Co e Cu iculum o he Ca diologis EAPC Co e Cu iculum o P e en i e Ca diology Popula ion science and public heal h •Design, implemen , and e alua e p e en i e in e en ions a he popula ion le el P ima y p e en ion and isk ac- o managemen •Manage a pa ien wi h hype ension •Manage a pa ien wi h dyslipidaemia •Manage ca dio ascula aspec s in a diabe ic pa ien •Manage a ca diac pa ien in p ima y p e en ion •Manage indi iduals wi h mul i ac o ial ca dio ascula isk p o iles •Manage a pa ien wi h non- adi ional ca dio ascula isk ac o s Seconda y p e en ion and ca - dio ascula ehabili a ion •Manage a ca diac pa ien in seconda y p e en ion •P esc ibe a p e en ion and ehabili a ion p o- g amme o a ca dio ascula pa ien •Manage a p e en ion and ehabili a ion p og amme o a ca dio ascula pa ien •Manage a p e en ion and ehabili a ion p og amme o a ca dio ascula pa ien wi h signi ican como bidi ies, ail y, and/o ca diac de ices •Manage a ca dio ascula p e en ion and ehabili a ion p og amme o an oncology pa ien Spo s ca diology and exe cise •Manage ca dio ascula aspec s in an a hle e •Manage p e-pa icipa ion sc eening in a compe i i e a hle e •Manage he wo k-up o an a hle e wi h suspec ed o known ca dio ascula disease All •Use ca diopulmona y exe cise es ing o diagnosis, isk s a i ica ion and exe cise p esc ip ion ESC Co e Cu iculum o P e en i e Ca diology 7 Downloaded om h ps://academic.oup.com/eu jpc/ad ance-a icle/doi/10.1093/eu jpc/zwab017/6207430 by Uni e sidade de Lisboa use on 22 Ap il 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2 Manage a pa ien wi h non- adi ional ca dio ascula isk ac o s (le el 4) 4.2 Manage he wo k-up o an a hle e wi h suspec ed o known ca dio ascula disease (le el 4) 5. Assessmen o clinical compe ences using EPA’s One impo an aspec in he concep o EPAs is he assessmen o clinical compe encies. EPAs p o ide a amewo k o aine s o pe - o m easy, o ma i e and epea ed assessmen s o ainees du ing hei sub-special y aining, which help o adjus he ainee’s le el o independence. 41 Op imally, hese assessmen s should be in eg a ed in o ou ine clinical ca e. The compe encies o he ainees will u - he inc ease a e comple ing he aining in line wi h hei con inu- ous p o essional de elopmen . Consul ing mo e expe ienced colleagues o o he expe s in complex cases should no be judged as need o supe ision, bu as a clinical eali y in imes o apid inc easing medical knowledge. When a ainee is able o execu e an EPA in ou ine cases in an independen manne and o assume he expec ed p o essional esponsibili ies, he highes le el o independ- ence is achie ed. Sui able ools o he assessmen o EPAs depend on he na u e o he ac i i y and a e p oposed in he assessmen sec ion o each EPA (Table 4). 41 Sou ces o knowledge in p e en i e ca diology In addi ion o speci ic guidelines and posi ion pape s p o ided a he end o each EPA, he ESC has published ou ex books in he ield o p e en i e ca diology as addi ional sou ce o comp ehensi e knowledge. 44 •ESC Tex book o P e en i e Ca diology 2015 •ESC Handbook o P e en i e Ca diology 2016 •ESC Tex book o Spo s Ca diology 2019 •ESC Handbook o Ca dio ascula Rehabili a ion 2020 Table 3 Le el o independence o a p o ession ac i - i y, adop ed om 41 Le el 1 T ainee is able o obse e Le el 2 T ainee is able o pe o m he ac i i y unde di ec supe ision (p oac i e, supe iso in he oom) Le el 3 T ainee is able o pe o m he ac i i y unde indi ec supe i- sion ( eac i e, on-demand supe ision, supe iso eadily a ailable) Le el 4 T ainee is able o pe o m he ac i i y unde dis an supe i- sion ( eac i e, supe ision a ailable emo ely o pos hoc) Le el 5 T ainee is able o pe o m he ac i i y wi hou supe ision and o supe ise o he s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Table 4 Tools o he assessmen o clinical compe- encies, adop ed om he ESC Co e Cu iculum o he Ca diologis 41 Knowledge •Sel -assessmen wi d mul iple choice ques ions (MCQs), e.g. p o ided a e a webina Skills •Case-based discussions •Di ec obse a ion o p ocedu al skills (DOPS) •Wo kplace-based assessmen s •Mini clinical e alua ion exe cise (mini-CEX) A i udes •Mul iple consul an epo s •Mul i-sou ce eedback Desc ip ion Scope and ime ame: All public heal h in e en ions in he ield o CVD p e en ion F om iden i ying he need o in e en ions o e alua ing he e ec o he in e en ions in popula ions Se ing: Communi y se ing Including: Iden i ica ion o po en ial needs o a popula ion and p e en i e in e en ions Re iew o pas and ongoing communi y coho s Selec ion o he app op ia e li es yle and pha macological in e en ions Se ing up budge , ime ame, miles ones, and main ou comes o he in e en ions Se ing up he c i e ia o he e alua ion o he in e en ions Se ing up occupa ional heal h p og ammes Se ing up popula ion sc eening p og ammes (e.g. schools, wo kplaces) Con inued Chap e 1: Popula ion science and public heal h 1.1 Design, implemen and e alua e p e en i e in e en ions a he popula ion le el 8M. Wilhelm e al. Downloaded om h ps://academic.oup.com/eu jpc/ad ance-a icle/doi/10.1093/eu jpc/zwab017/6207430 by Uni e sidade de Lisboa use on 22 Ap il 2021 Con inued CanMEDS oles Medical expe Communica o Collabo a o Leade Heal h ad oca e Schola P o essional Knowledge Iden i y a ge popula ions and p e en i e in e en ions, including g oups cu en ly unde ep esen ed in clinical s udies (women, olde people, e hnic mino i ies, mig an s) App aise he e idence ega ding popula ion-based app oaches o p e en ion (e.g. epidemiology, andomized con olled ials, and cos e ec i eness s udies) Be awa e o po en ial s akeholde s and collabo a o s Design s udies o check sa e y and success o in e en ions Desc ibe esea ch me hodology o collec da a/ un analysis/syn hesize esul s o s udy ou comes/use audi ools Skills Build a ne wo k o collabo a o s o iden i y and engage wi h key s akeholde s, including policy make s, heal h se ices, heal hca e p o essionals, aca- demia, and membe s o he public Conduc a needs assessmen o iden i y he popula ion p io i ies based on good knowledge o he local popula ion In eg a e ecommended in e en ions in o exis ing p e en i e s a egies on a popula ion le el Design he in e en ions Pe o m powe calcula ions o de e mine sample sizes equi ed o e alua e he in e en ions wi h con idence C ea e, alida e, and implemen da a collec ion ools (ques ionnai es, ins umen s o collec clinical da a) E alua e s a is ical me hods o analyse da a aking in o accoun possible biases/con ounde s. Calcula e he cos -e ec i eness o in e en ions Use ea ly public in ol emen and engagemen Engage communica ion channels o publicize he in e en ions Dissemina e esul s o p o essionals, he public and poli icians E alua e e ec i eness o implemen ed in e en ions, and ecommend adjus men s in p e en i e s a egy i needed Mange p ojec s app op ia ely A i udes Collabo a e/nego ia e wi h o he s akeholde s in planning o s udy Communica e o ensu e ha he in e en ion is unde s ood by he a ge popula ion, he s akeholde s and poli icians Consis en ly e alua e he in e en ion and adjus i acco ding o he local esul s Assessmen ools Mul iple choice ques ions (MCQs) Case-based discussions, en us men -based discussions Mul i-sou ce eedback Simula ion o popula ion in e en ions P esen a ion and publica ion o esul s o he in e en ion Le el o independence Le el 3 (pe o m he ac i i y unde indi ec supe ision. In his con ex , his means o con ibu e o design, implemen a ion, and e alua ion o p e en i e in e en ions, and coope a e wi h pa ne s om popula ion science and public heal h, bu no necessa ily o ake he lead in hese ype o p ojec s) Rela ed ESC guidelines and EAPC posi ion pape s Timmis A, Townsend N, Gale CP, e al. Eu opean Socie y o Ca diology: ca dio ascula disease s a is ics 2019. Eu Hea J 2020;41:12–85. A ena R, Guazzi M, Liano L, e al. Heal hy li es yle in e en ions o comba noncommunicable disease-a no el nonhie a chical connec i i y model o key s akeholde s: a policy s a emen om he Ame ican Hea Associa ion, Eu opean Socie y o Ca diology, Eu opean Associa ion o Ca dio ascula P e en ion and Rehabili a ion, and Ame ican College o P e en i e Medicine. Eu Hea J 2015;36:2097–2109. Jo gensen T, Capewell S, P esco E, e al. Popula ion-le el changes o p omo e ca dio ascula heal h. Eu J P e Ca diol 2013;20:409–421. ESC Co e Cu iculum o P e en i e Ca diology 9 Downloaded om h ps://academic.oup.com/eu jpc/ad ance-a icle/doi/10.1093/eu jpc/zwab017/6207430 by Uni e sidade de Lisboa use on 22 Ap il 2021 Con inued Skills Manage speci ic aspec s o indi idual como bidi ies: s oke, PAOD, diabe es, ch onic kidney disease, ch onic obs uc i e pulmona y disease, heuma o- logic disease, o hopaedic disease, and ail y Manage speci ic aspec s o CIED, LVAD and hea ansplan pa ien s Pe o m e alua ion including CV isk ac o s, clinical condi ion, non-in asi e assessmen o CV unc ioning/disease, disabili ies, nu i ion, psycho-social impac Explo e pa ien expec a ions, alues and p io i ies Pe o m and in e p e exe cise capaci y es s (ECG exe cise es ing, CPET, 6MWT, s eng h es s) o ailo ed exe cise p esc ip ions P esc ibe endu ance con inuous/in e al aining, esis ance/s eng h aining, and espi a o y aining De elop exe cise aining acco ding o se ings ( esiden ial, ambula o y, communi y-based, ele-moni o ing), pa ien condi ions (age, sex, como bidi ies, psychologic s a us), and p e e ences Concep ualize, o ganize and d i e an educa ional p og amme wi h speci ici ies o he di e en como bidi ies O ganize a ele-moni o ing/ ele- ehabili a ion p og amme Op imize and up- i a e guideline-di ec ed medical he apies, adap ed o he exe cise ole ance and como bidi ies Iden i y and analyse CIED unc ioning a es and du ing e o Manage como bidi ies unde conside a ion o possible d ug in e ac ions and con aindica ions Recognize and ea eme gency cases ela ed o como bidi ies o de ices Manage pa ien s wi h esidual ischaemia (e.g. incomple e op imal e ascula iza ion, di use a he oscle o ic disease) De ec pos -in e en ional o pos -su gical complica ions (e.g. ea ly s en h ombosis o es enosis, pe ica dial amponade) Apply e ec i e communica ion and beha iou al change echniques (e.g. mo i a ional in e iewing o smoking cessa ion and pa ien educa ion) Make end o li e discussions possible o e minal pa ien s O ganize he ollow-up, links wi h gene al p ac i ione s and/o ca diologis s, and o he heal h p o essionals A i udes Wo k wi h in e disciplina y eams o heal h p o essionals in ol ed in seconda y p e en ion and ehabili a ion Educa e and encou age pa ien s o educe hei CV isk ac o s wi h help o all he p o essional esou ces Educa e pa ien s on how his/he en ou age can suppo p e en ion Suppo pa ien s wi h gene ic diso de s (psychological counselling, explain consequences o disease managemen and o ela i es) Mo i a e pa ien s o sus ain long- e m adhe ence wi h li es yle, exe cise aining, and medical he apy, despi e hei como bidi ies Ac i ely in ol e pa ien s in sha ed decision-making o p omo e op imal sel -managemen and long e m adhe ence o beha iou change Ad oca e o comp ehensi e CV p e en ion and ehabili a ion p og ammes o imp o e e e al and up ake Assessmen ools MCQs Di ec obse a ion, wo kplace-based assessmen s (e.g. DOPS, mini-CEX, ieldno es) Case-based discussions, en us men -based discussions Mul iple consul an epo s Mul i-sou ce eedback Le el o independence Le el 5 (pe o m he ac i i y wi hou supe ision, each and supe ise o he s) Rela ed ESC guidelines and EAPC posi ion pape s Ped e i RF, Iliou MC, Is ael CW e al. Comp ehensi e mul icomponen ca diac ehabili a ion in ca diac implan able elec onic de ices ecipien s. A consensus documen om he Eu opean Associa ion o P e en i e Ca diology (EAPC; Sec ion on Seconda y P e en ion and Rehabili a ion) and Eu opean Hea Rhy hm Associa ion (EHRA). Eu J P e Ca diol 2020;doi:10.1093/eu jpc/zwaa121. Amb ose i M, Ab eu A, Co a U, e al. Seconda y p e en ion h ough comp ehensi e ca dio ascula ehabili a ion: om knowledge o implemen a ion. 2020 upda e. A posi ion pape om he Seconda y P e en ion and Rehabili a ion Sec ion o he Eu opean Associa ion o P e en i e Ca diology. Eu J P e Ca diol 2020;doi:10.1177/2047487320913379. Ab eu A, F ede ix I, Dendale P, e al. S anda diza ion and quali y imp o emen o seconda y p e en ion h ough ca dio ascula ehabili a ion p o- g ammes in Eu ope: he a enue owa ds EAPC acc edi a ion p og amme: A posi ion s a emen o he Seconda y P e en ion and Rehabili a ion Sec ion o he Eu opean Associa ion o P e en i e Ca diology (EAPC). Eu J P e Ca diol 2020;doi:10.1177/2047487320924912. Sche enbe g M, Wilhelm M, Hansen D, e al. The u u e is now: a call o ac ion o ca diac ele ehabili a ion in he COVID-19 pandemic om he sec- onda y p e en ion and ehabili a ion sec ion o he Eu opean Associa ion o P e en i e Ca diology. Eu J P e Ca diol 2020;doi:10.1177/ 2047487320939671. Hansen D, K aenkel N, Kemps H, e al. Managemen o pa ien s wi h ype 2 diabe es in ca dio ascula ehabili a ion. Eu J P e Ca diol 2019;26:133–144. Kemps H, K ankel N, Do M, e al. Exe cise aining o pa ien s wi h ype 2 diabe es and ca dio ascula disease: Wha o pu sue and how o do i . A Posi ion Pape o he Eu opean Associa ion o P e en i e Ca diology (EAPC). Eu J P e Ca diol 2019;26:709–727. Con inued 16 M. Wilhelm e al. Downloaded om h ps://academic.oup.com/eu jpc/ad ance-a icle/doi/10.1093/eu jpc/zwab017/6207430 by Uni e sidade de Lisboa use on 22 Ap il 2021 Con inued Vigo i o C, Ab eu A, Amb ose i M, Bela dinelli R, Co a U, Cupples M, Da os CH, Hoe e S, Iliou MC, Schmid JP, Voelle H, Dohe y P. F ail y and ca - diac ehabili a ion: A call o ac ion om he EAPC Ca diac Rehabili a ion Sec ion. Eu J P e Ca diol 2017;24:577–590. Piepoli MF, Hoes AW, Agewall S, e al. 2016 Eu opean Guidelines on ca dio ascula disease p e en ion in clinical p ac ice: he Six h Join Task Fo ce o he Eu opean Socie y o Ca diology and O he Socie ies on Ca dio ascula Disease P e en ion in Clinical P ac ice (cons i u ed by ep esen a i es o 10 socie ies and by in i ed expe s)De eloped wi h he special con ibu ion o he Eu opean Associa ion o Ca dio ascula P e en ion & Rehabili a ion (EACPR). Eu Hea J 2016;37:2315–2381. Upda e in 2021. Mezzani A, Hamm LF, Jones AM, e al. Ae obic exe cise in ensi y assessmen and p esc ip ion in ca diac ehabili a ion: a join posi ion s a emen o he Eu opean Associa ion o Ca dio ascula P e en ion and Rehabili a ion, he Ame ican Associa ion o Ca dio ascula and Pulmona y Rehabili a ion and he Canadian Associa ion o Ca diac Rehabili a ion. Eu J P e Ca diol 2013;20:442–467. Piepoli MF, Con aads V, Co a U, e al. Exe cise aining in hea ailu e: om heo y o p ac ice. A consensus documen o he Hea Failu e Associa ion and he Eu opean Associa ion o Ca dio ascula P e en ion and Rehabili a ion. Eu J Hea Fail 2011;13:347–357. Desc ip ion Scope and ime ame: Cance pa ien s, in pa icula a e ca dio oxic cance he apy, om cance diagnosis o ollow-up su eillance Se ing: In-pa ien , ou -pa ien , home based, communi y, i ual (including online and ele ehabili a ion) Including: Assessmen o he clinical s a us, iden i ica ion o isk ac o s o CVD and cance , using basic and ad anced ools o in es iga ion; pha macological and non- pha macological ea men Excluding: Pe o ming specialis in es iga ions o in e en ional o su gical p ocedu es, acu e o uns able condi ion, acu e se ings CanMEDS-Roles Medical expe Communica o Collabo a o Leade Heal h ad oca e Schola P o essional Knowledge Iden i y clinical in e ac ions be ween cance and CVDs Iden i y isk ac o s common o cance and CVD (e.g. ageing, smoking, alcohol abuse, unbalanced die and physical inac i i y) Desc ibe CV oxici y o speci ic chemo- and adio he apies in cance pa ien s unde going ea men as well as cance su i o s and i s in luence on exe - cise capaci y and quali y o li e Desc ibe he p ognosis o di e en cance s Discuss he speci ic ehabili a ion needs o cance pa ien s wi h o a isk o CVD (exe cise, psychological, p e en ion, social, educa ion) Desc ibe he ole o exe cise in ca dio-oncology ehabili a ion o minimize he nega i e e ec s o cance he apies (e.g. ca dio- oxici y, a igue, bone loss, lymphoedema, au onomic dys unc ion, dep ession, anxie y) Discuss indica ions and in e p e a ion o exe cise capaci y es s (ECG exe cise es ing, CPET, 6MWT, s eng h es s) Desc ibe he ole o exe cise and ca dio-oncology ehabili a ion o limi cance p og ession and elapses Discuss he s a egies o limi disabili ies, impai ed quali y o li e and psychosocial dis ess induced by cance and CVD Skills Di e en ia e ca dio-oncology ehabili a ion in cance pa ien s om con en ional oncology ehabili a ion Iden i y cance pa ien s wi h expec ed g ea e bene i s om ca dio-oncology ehabili a ion Adap comp ehensi e ca dio-oncology ehabili a ion o he cance si ua ion (ac i e cance o cance su i o s) Pe o m and in e p e exe cise capaci y es s (ECG exe cise es ing, CPET, 6MWT, s eng h es s) o ailo ed exe cise p esc ip ions In e p e imaging in es iga ions pe o med in oncology pa ien s and de i e p ognos ic in o ma ion Con inued 3.3 Manage a ca dio ascula p e en ion and ehabili a ion p og amme o an oncology pa ien ESC Co e Cu iculum o P e en i e Ca diology 17 Downloaded om h ps://academic.oup.com/eu jpc/ad ance-a icle/doi/10.1093/eu jpc/zwab017/6207430 by Uni e sidade de Lisboa use on 22 Ap il 2021 Iden i y he app op ia e ca dio-oncology ehabili a ion se ing ( esiden ial, ou -pa ien s, cen e-based, communi y-based, home-based) acco ding o pa ien ’s p e e ences and possibili ies Re iew cance his o y, cance he apies and ela ed side e ec s, d ug in e ac ions E alua e he isk o CVD in ac i e cance and cance su i o s Es ablish goals o isk ac o s con ol modula ed by he p esence o his o y o cance Selec he app op ia e me hod o unc ional es ing in cance pa ien s E alua e and ea cance - ela ed cachexia, sa copenia and anaemia Adap ype and in ensi y o aining o cance localiza ion, cance s ages and speci ic sequelae (e.g. app op ia e in ensi y in case o cachexia o ail y, ole o uppe body s eng h aining in b eas cance , ole o inspi a o y muscle aining in ho acic cance ) In e disciplina y wo k wi h he oncology eam, and o he heal hca e p o essionals Make end o li e discussions possible o e minal pa ien s P o ide iew/opinion abou e u n o wo k A i udes Aim o dec ease he isk o CVD in cance pa ien s Conside ca dio-oncology ehabili a ion as a s anda d o ca e o cance pa ien s and su i o s a high isk o CVD Deal op imis ically wi h cance Collabo a e wi h oncologis s and o he ca e p o ide s in he ield o oncology Reassu e and mo i a e cance pa ien s Assessmen ools MCQs Di ec obse a ion, wo kplace-based assessmen s (e.g. DOPS, mini-CEX, ieldno es) Case-based discussions, en us men -based discussions Mul iple consul an epo s Mul i-sou ce eedback Le el o Independence Le el 5 (pe o m he ac i i y wi hou supe ision, each and supe ise o he s) Rela ed ESC guidelines and EAPC posi ion pape s Zamo ano JL, Lancello i P, Rod iguez Munoz D, e al. 2016 ESC Posi ion Pape on cance ea men s and ca dio ascula oxici y de eloped unde he auspices o he ESC Commi ee o P ac ice Guidelines: he Task Fo ce o cance ea men s and ca dio ascula oxici y o he Eu opean Socie y o Ca diology (ESC). Eu Hea J 2016;37:2768–2801. Rela ed AHA Scien i ic S a emen Gilch is SC, Ba ac A, Ades PA, e al. Ca dio-oncology ehabili a ion o manage ca dio ascula ou comes in cance pa ien s and su i o s: a scien i ic s a emen om he Ame ican Hea Associa ion. Ci cula ion 2019;139:e997–e1012. Desc ip ion Scope and ime ame: Compe i i e a hle es, om e alua ion o eligibili y o compe i ion Se ing: Ou -pa ien se ing Including: E alua ion o pe sonal and amily his o y (including habi ual physical ac i i y le el, spo ype, i ness), physical examina ion, blood p essu e measu emen , 12- lead ECG, u he es ing (ambula o y ECG moni o ing, echoca diog aphy, ad anced imaging, exe cise es ing, CPET), i app op ia e Iden i ica ion o po en ial high- isk a hle es o sudden ca diac dea h and o o he CV condi ions ha may wo sen because o in ensi e a hle ic aining Excluding: Pe o ming specialis in es iga ions o in e en ional o su gical p ocedu es CanMEDS oles Medical expe Communica o Collabo a o Con inued Chap e 4: Spo s ca diology and exe cise 4.1 Manage p e-pa icipa ion e alua ion in a compe i i e a hle e 18 M. Wilhelm e al. Downloaded om h ps://academic.oup.com/eu jpc/ad ance-a icle/doi/10.1093/eu jpc/zwab017/6207430 by Uni e sidade de Lisboa use on 22 Ap il 2021 Leade Heal h ad oca e Schola P o essional Knowledge Desc ibe physiological adap a ions o acu e and ch onic exe cise Desc ibe physiological adap a ions in di e en si ua ions such as deep sea, high al i ude, low o high empe a u es Assess he ype o p ac iced spo (skill, powe , mixed, endu ance), he speci ic me abolic ea u es and induced CV emodelling Desc ibe he physiological CV adap a ion induced by egula exe cise and he no mal s. bo de line ECG indings in a hle es Desc ibe he incidence o sudden ca diac dea h in a hle es and he mos equen and eme gen CV condi ions in ol ed Desc ibe CV condi ions ha may wo sen because o in ensi e a hle ic aining and hose ha will bene i om p ima y p e en ion Desc ibe how o es ablish a diagnos ic lowcha o sudden dea h p e en ion in he p esence o abno mal indings (including ECG and physical examin- a ion indings) du ing p e-pa icipa ion e alua ion (PPE) in a hle es Desc ibe indica ions o ca diac mul i-modali y imaging and gene ic es ing in PPE Discuss he CV e ec s o he main doping subs ances Skills Ob ain a ele an his o y and pe o m an app op ia e physical examina ion, including habi ual physical ac i i y le el and spo ype (skill, powe , mixed, endu ance) E alua e he CV isk p o ile based on app op ia e isk calcula o s and he i ness le el o an a hle e o e 35 yea s o age and he bu den o isk ac o s o CVD Unde s and he esul s o physical examina ion and 12-lead ECG showing physiological, bo de line o pa hological indings Iden i y he po en ial high- isk a hle es and u he e alua e he isk o sudden ca diac dea h o accele a ion o an inhe i ed p edisposi ion o exace ba- ion o ca diac damage due o in e cu en illness esul ing om in ense and p olonged exe cise. E alua e po en ial doping issues and subs ance abuse Choose he app op ia e sc eening modali y in he p esence o abno mal indings (e.g. ECG exe cise es , CPET, echoca diog aphy, ambula o y ECG moni o ing, ca diac compu ed omog aphy angiog aphy, ca diac magne ic esonance, gene ic es ing) Pe o m and in e p e ECG exe cise es , CPET, echoca diog aphy, ambula o y ECG moni o ing i indica ed In eg a e esul s om ad anced CV imaging and gene ic es ing in clinical decision-making Ad ise ega ding exe cise and exe cise aining in a hle es wi h ca diac disease acco ding o his o y, clinical inding, diagnos ics and CPET A i udes Adop a non-judgemen al a i ude o an a hle e ega ding he /his li es yle o e e ed symp oms, i any Communica e wi h he a hle e, amily, and he eam physician o op imize he managemen o po en ially abno mal indings du ing PPE and how his may a ec spo s eligibili y Communica e concep s o exe cise and exe cise p og amme wi h he a hle e Mo i a e he a hle e o sys ema ically unde go PPE and explain he cos -e ec i eness conside a ion o his model Assessmen ools MCQs Di ec obse a ion, wo kplace-based assessmen s (e.g. DOPS, mini-CEX, ieldno es) Case-based discussions, en us men -based discussions Mul iple consul an epo s Mul i-sou ce eedback Le el o independence Le el 5 (pe o m he ac i i y wi hou supe ision, each and supe ise o he s) Rela ed ESC guidelines and EAPC posi ion pape s Pelliccia A, Sha ma S, Ga i S, e al. 2020 ESC Guidelines on spo s ca diology and exe cise in pa ien s wi h ca dio ascula disease. Eu Hea J 2020;doi:10.1093/eu hea j/ehaa605. Bud s W, Pieles GE, Roos-Hesselink JW, e al. Recommenda ions o pa icipa ion in compe i i e spo in adolescen and adul a hle es wi h Congeni al Hea Disease (CHD): posi ion s a emen o he Spo s Ca diology & Exe cise Sec ion o he Eu opean Associa ion o P e en i e Ca diology (EAPC), he Eu opean Socie y o Ca diology (ESC) Wo king G oup on Adul Congeni al Hea Disease and he Spo s Ca diology, Physical Ac i i y and P e en ion Wo king G oup o he Associa ion o Eu opean Paedia ic and Congeni al Ca diology (AEPC). Eu Hea J 2020;doi:10.1093/eu hea j/ ehaa501. Heidbuchel H, Adami PE, An z M, e al. Recommenda ions o pa icipa ion in leisu e- ime physical ac i i y and compe i i e spo s in pa ien s wi h a hy hmias and po en ially a hy hmogenic condi ions: Pa 1: Sup a en icula a hy hmias. A posi ion s a emen o he Sec ion o Spo s Ca diology and Exe cise om he Eu opean Associa ion o P e en i e Ca diology (EAPC) and he Eu opean Hea Rhy hm Associa ion (EHRA), bo h associa ions o he Eu opean Socie y o Ca diology. Eu J P e Ca diol 2020;doi:10.1177/2047487320925635. Con inued ESC Co e Cu iculum o P e en i e Ca diology 19 Downloaded om h ps://academic.oup.com/eu jpc/ad ance-a icle/doi/10.1093/eu jpc/zwab017/6207430 by Uni e sidade de Lisboa use on 22 Ap il 2021 Heidbuchel H, A belo E, D’Ascenzi F, e al. Recommenda ions o pa icipa ion in leisu e- ime physical ac i i y and compe i i e spo s o pa ien s wi h a hy hmias and po en ially a hy hmogenic condi ions. Pa 2: en icula a hy hmias, channelopa hies, and implan able de ib illa o s. Eu opace 2020;doi:10.1093/eu opace/euaa106. Pelliccia A, Solbe g EE, Papadakis M, e al. Recommenda ions o pa icipa ion in compe i i e and leisu e ime spo in a hle es wi h ca diomyopa hies, myoca di is, and pe ica di is: posi ion s a emen o he Spo Ca diology Sec ion o he Eu opean Associa ion o P e en i e Ca diology (EAPC). Eu Hea J 2019;40:19–33. Bo jesson M, Dellbo g M, Niebaue J, e al. Recommenda ions o pa icipa ion in leisu e ime o compe i i e spo s in a hle es-pa ien s wi h co ona y a e y disease: a posi ion s a emen om he Spo s Ca diology Sec ion o he Eu opean Associa ion o P e en i e Ca diology (EAPC). Eu Hea J 2019;40:13–18. Niebaue J, Bo jesson M, Ca e F, e al. Recommenda ions o pa icipa ion in compe i i e spo s o a hle es wi h a e ial hype ension: a posi ion s a e- men om he spo s ca diology sec ion o he Eu opean Associa ion o P e en i e Ca diology (EAPC). Eu Hea J 2018;39:3664–3671. Mon L, Pelliccia A, Sha ma S, e al. P e-pa icipa ion ca dio ascula e alua ion o a hle ic pa icipan s o p e en sudden dea h: Posi ion pape om he EHRA and he EACPR, b anches o he ESC. Endo sed by APHRS, HRS, and SOLAECE. Eu opace 2017;19:139–163. Desc ip ion Scope and ime ame: Leisu e- ime and compe i i e a hle es, om he ime he a hle e wi h suspec ed o known CVD sel - e e s o is e e ed o a consul a ion un il egula ol- low-up Se ing: Mos commonly ou -pa ien se ing, bu also in-pa ien se ing and eme gency depa men Including: Assessmen wi h his o y, physical examina ion, basic and ad anced ools o in es iga ion, di e en ia ion o physiological adap a ion o exe cise om pheno- ypes o CVD, iden i ica ion o isk ac o s o sudden ca diac dea h and high- isk condi ions, ecommenda ion o li es yle and pha macological ea men , exe cise p esc ip ion and counselling on leisu e- ime and compe i i e spo s Excluding: Pe o ming specialis in es iga ions o in e en ional o su gical p ocedu es, in e p e ing gene ic es esul s CanMEDS oles Medical expe Communica o Collabo a o Leade Heal h ad oca e Schola P o essional Knowledge Desc ibe pheno ypes o physiological adap a ion o exe cise Recognize he challenges o di e en ia ing a hle e’s hea om hea disease Iden i y isk ac o s o sudden ca diac dea h and high- isk condi ions Ou line non-pha macological and pha macological ea men o a hle es wi h common CV condi ions Ou line exe cise ecommenda ions in a hle es wi h CVD Recognize he e hical and legal conside a ions o disquali ica ion om compe i i e spo s pa icipa ion Skills Ob ain a ocused his o y and pe o m app op ia e physical examina ion P opose and pe o m app op ia e non-in asi e, i s -line clinical in es iga ions (12-lead ECG, ans ho acic echoca diog am, exe cise es ing/CPET, ECG moni o ) o assess a hle es wi h suspec ed o known ca diac disease P opose u he app op ia e ad anced in es iga ions, including gene ic es ing In eg a e he esul s in an in e disciplina y se ing Illus a e how isk s a i ica ion o a hle es wi h CVD in o ms hei managemen P esc ibe ailo ed exe cise ecommenda ions based on CPET Implemen ecommenda ions o exe cise p esc ip ion and eligibili y o pa icipa ion in compe i i e spo in a hle es wi h ca diac disease P esc ibe comp ehensi e CV p e en ion and ehabili a ion o a hle es wi h CVD, i indica ed, and adop p og ammes app op ia ely Con inued 4.2 Manage he wo k-up o an a hle e wi h suspec ed o known ca dio ascula disease 20 M. Wilhelm e al. Downloaded om h ps://academic.oup.com/eu jpc/ad ance-a icle/doi/10.1093/eu jpc/zwab017/6207430 by Uni e sidade de Lisboa use on 22 Ap il 2021 A i udes In eg a e he esul s o in es iga ions in an in e disciplina y se ing Communica e e ec i ely esul s and exe cise ecommenda ions o he a hle es, eam doc o s, coaches, amilies P omo e a sha ed-decision-making model, pa icula ly in condi ions wi h limi ed e idence ela ing o he isk o exe cise Adop a holis ic app oach o he impac o exe cise es ic ion and disquali ica ion om compe i i e spo s on an a hle e, in e ms o psychological, phys- ical, and inancial wellbeing Assessmen ools MCQs Di ec obse a ion, wo kplace-based assessmen s (e.g. DOPS, mini-CEX, ieldno es) Case-based discussions, en us men -based discussions Mul iple consul an epo s Mul i-sou ce eedback Le el o independence Le el 4 (pe o m he ac i i y unde dis an supe ision. In his con ex his means o wo k in a ne wo k wi h dedica ed spo s ca diology e e al cen es in complica ed cases) Rela ed ESC guidelines and EAPC posi ion pape s Pelliccia A, Sha ma S, Ga i S, e al. 2020 ESC Guidelines on spo s ca diology and exe cise in pa ien s wi h ca dio ascula disease. Eu Hea J 2020;doi:10.1093/eu hea j/ehaa605. Bud s W, Pieles GE, Roos-Hesselink JW, e al. Recommenda ions o pa icipa ion in compe i i e spo in adolescen and adul a hle es wi h Congeni al Hea Disease (CHD): posi ion s a emen o he Spo s Ca diology & Exe cise Sec ion o he Eu opean Associa ion o P e en i e Ca diology (EAPC), he Eu opean Socie y o Ca diology (ESC) Wo king G oup on Adul Congeni al Hea Disease and he Spo s Ca diology, Physical Ac i i y and P e en ion Wo king G oup o he Associa ion o Eu opean Paedia ic and Congeni al Ca diology (AEPC). Eu Hea J 2020;doi:10.1093/eu hea j/ ehaa501. Heidbuchel H, Adami PE, An z M, e al. Recommenda ions o pa icipa ion in leisu e- ime physical ac i i y and compe i i e spo s in pa ien s wi h a hy hmias and po en ially a hy hmogenic condi ions: Pa 1: Sup a en icula a hy hmias. A posi ion s a emen o he Sec ion o Spo s Ca diology and Exe cise om he Eu opean Associa ion o P e en i e Ca diology (EAPC) and he Eu opean Hea Rhy hm Associa ion (EHRA), bo h associa ions o he Eu opean Socie y o Ca diology. Eu J P e Ca diol 2020;doi:10.1177/2047487320925635. Heidbuchel H, A belo E, D’Ascenzi F, e al. Recommenda ions o pa icipa ion in leisu e- ime physical ac i i y and compe i i e spo s o pa ien s wi h a hy hmias and po en ially a hy hmogenic condi ions. Pa 2: en icula a hy hmias, channelopa hies, and implan able de ib illa o s. Eu opace 2020;doi:10.1093/eu opace/euaa106. Pelliccia A, Solbe g EE, Papadakis M, e al. Recommenda ions o pa icipa ion in compe i i e and leisu e ime spo in a hle es wi h ca diomyopa hies, myoca di is, and pe ica di is: posi ion s a emen o he Spo Ca diology Sec ion o he Eu opean Associa ion o P e en i e Ca diology (EAPC). Eu Hea J 2019;40:19–33. Bo jesson M, Dellbo g M, Niebaue J, e al. Recommenda ions o pa icipa ion in leisu e ime o compe i i e spo s in a hle es-pa ien s wi h co ona y a e y disease: a posi ion s a emen om he Spo s Ca diology Sec ion o he Eu opean Associa ion o P e en i e Ca diology (EAPC). Eu Hea J 2019;40:13–18. Niebaue J, Bo jesson M, Ca e F, e al. Recommenda ions o pa icipa ion in compe i i e spo s o a hle es wi h a e ial hype ension: a posi ion s a e- men om he spo s ca diology sec ion o he Eu opean Associa ion o P e en i e Ca diology (EAPC). Eu Hea J 2018;39:3664–3671. Desc ip ion Scope and ime ame: Heal hy indi iduals, a hle es, indi iduals wi h CVD isk ac o s, and CVD pa ien s. F om indica ion o using CPET un il communica ing he esul s Se ing: In-pa ien , ou -pa ien , exe cise physiology labo a o y, on ield Including: Pe o ming a comp ehensi e CPET on a bicycle o eadmill, o o he ypes o e gome e s, o using mobile de ices unde eal-li e condi ions (i.e. pa ien ’s wo kplace, a hle e on he ield), wi h and wi hou in asi e measu emen s, in e p e ing and epo ing he esul s Excluding: Complex cases wi h a p edominan pulmona y p oblem which should be managed in coope a ion wi h a pulmona y specialis Con inued Chap e 5: Ca diopulmona y exe cise es ing 5.1 Use ca diopulmona y exe cise es ing o diagnosis, isk s a i ica ion and exe cise p esc ip ion ESC Co e Cu iculum o P e en i e Ca diology 21 Downloaded om h ps://academic.oup.com/eu jpc/ad ance-a icle/doi/10.1093/eu jpc/zwab017/6207430 by Uni e sidade de Lisboa use on 22 Ap il 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . Supplemen a y ma e ial Supplemen a y ma e ial is a ailable a Eu opean Jou nal o P e en i e Ca diology online. Con lic o in e es : MP ecei ed esea ch g an s om he cha i - able o ganisa ion Ca diac Risk in he Young which suppo s ca diac sc eening o young indi iduals. No o he au ho decla ed a con lic o in e es in he con ex o his co e cu iculum. Re e ences 1. Nabel EG, B aunwald E. A ale o co ona y a e y disease and myoca dial in a c- ion. N Engl J Med 2012;366:54–63. 2. Timmis A, Townsend N, Gale CP, To bica A, Le ino M, Pe e sen SE, Mossialos EA, Maggioni AP, Kazakiewicz D, May HT, De Smed D, Fla he M, Zuhlke L, Bel ame JF, Huculeci R, Ta azzi L, Hind icks G, Bax J, Casadei B, Achenbach S, W igh L, Va das P; Eu opean Socie y o Ca diology. Eu opean Socie y o Ca diology: ca dio ascula disease s a is ics 2019. Eu Hea J 2020;41: 12–85. 3. Piepoli MF, Hoes AW, Agewall S, Albus C, B o ons C, Ca apano AL, Cooney MT, Co a` U, Cosyns B, Dea on C, G aham I, Hall MS, Hobbs FDR, Løchen ML, CanMEDS oles Medical expe Communica o Collabo a o Schola P o essional Knowledge Unde s and CV exe cise physiology and ca dio espi a o y i ness Lis he indica ions and con aindica ions o CPET in heal hy indi iduals, pa ien s wi h CVD, and a hle es Know he isk o CPET in in ec i e pa ien s and p e en i e measu es o he pe sonal Know he po en ial complica ions o CPET De ine he key a iables o CPET Discuss he in e p e a ion o he nine-panel plo Discuss he indica ions o and alue o addi ional blood gas analysis Desc ibe pa e ns o pulmona y, ca diac, and muscula condi ions Lis and de ec pi alls and a e ac s o CPET Desc ibe he ole o combining CPET wi h o he (haemodynamic) e alua ions (e.g. echoca diog aphy, igh hea ca he e iza ion) Desc ibe he o e lapping and disc imina ing concep s o CPET and lac a e es ing Skills Apply app op ia e indica ions and a oid con aindica ion o CPET Pe o m CPET calib a ion and quali y con ol P epa e he pa ien o a hle e Choose he app op ia e exe cise p o ocol and de ice In e p e he nine-panel plo Fo mula e a unc ion-based diagnosis and p ognos ic s a i ica ion Fo mula e exe cise aining ecommenda ions based on en ila o y h esholds Communica e he esul s app op ia ely A i udes In eg a e CPET in he e alua ion o heal hy indi iduals, CV pa ien s and a hle es Recognize he s eng hs and weaknesses o CPET in a clinical si ua ion and in ela ion o o he diagnos ic modali ies In e ac coope a i ely wi h spo s physicians, spo s scien is s, and pa amedical s a in ol ed in he execu ion o he es Assessmen ools MCQs Di ec obse a ion, wo kplace-based assessmen s (e.g. DOPS, mini-CEX, ieldno es) Case-based discussions, en us men -based discussions Mul iple consul an epo s Le el o independence Le el 5 (pe o m he ac i i y wi hou supe ision, each and supe ise o he s) Rela ed ESC guidelines and EAPC posi ion pape s Guazzi M, Adams V, Con aads V, e al. EACPR/AHA Join Scien i ic S a emen . Clinical ecommenda ions o ca diopulmona y exe cise es ing da a as- sessmen in speci ic pa ien popula ions. Eu Hea J 2012;33:2917–2927. Guazzi M, A ena R, Halle M, e al. 2016 ocused upda e: clinical ecommenda ions o ca diopulmona y exe cise es ing da a assessmen in speci ic pa- ien popula ions. Eu Hea J 2018;39:1144–1161. Mezzani A, Hamm LF, Jones AM, e al. Ae obic exe cise in ensi y assessmen and p esc ip ion in ca diac ehabili a ion: a join posi ion s a emen o he Eu opean Associa ion o Ca dio ascula P e en ion and Rehabili a ion, he Ame ican Associa ion o Ca dio ascula and Pulmona y Rehabili a ion and he Canadian Associa ion o Ca diac Rehabili a ion. Eu J P e Ca diol 2013;20:442–467. 22 M. Wilhelm e al. 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