St Paul, MN - The American Board of Medical Specialties (ABMS) has approved a proposal to establish a subspecialty certification in "advanced heart failure and transplant cardiology," the Heart Failure Society of America (HFSA) has announced [1]. The HFSA was a prime mover in the effort to establish the certification, which it hopes will promote quality and guarantee a degree of consistency in the training and expertise of physicians specializing in heart failure.

"All this came about when we recognized that there was a skill set that had coalesced around heart failure that was getting more and more complex," HFSA president Dr Barry H Greenberg (University of California, San Diego) told heartwire. "At the same time, institutions around the country were looking for bona fide heart-failure specialists, and there was really no way to identify them." Patients with advanced heart failure have complex issues for doctors to manage, "and we didn't want just anybody to say, I'm a heart-failure specialist."

Initially there was some concern by other constituencies that we might be overlapping them. But once they understood that this was going to deal with these advanced, complicated patients, that really kind of melted away.

The problem has been more than theoretical, according to an interview conducted for theheart.org's Fellows Corner [2] with former HFSA president Dr Marvin Konstam (Tufts University, Boston, MA). "The reality is that de facto this field exists. There are many people out there who refer to themselves as heart-failure specialists. There are 65 or so programs out there training people in what is called advanced heart failure," he said. "This is a field that has expanded and grown very much ahead of the certification and accreditation processes, and [that] really is the singular reason this had to happen. It really had to happen for the best interest of the patients with heart failure."

There are still some hurdles to clear before the first boards are administered, according to Konstam. They include lining up an accrediting organization and development of the examination itself. "I don't see any of that coming on realistically before 2010. It could even be pushed later than that."

Physicians who may already be prepared to take the boards won't be forced to enroll in an accredited training program, Konstam said. The proposal put forth by the American Board of Internal Medicine and accepted by ABMS contains "very clear opportunities," at least for the first several years of the process, for individuals to meet certain required criteria. "There are many people out there like that, including myself. There are ways of documenting your competence in these areas to qualify you for sitting for the exam."

Greenberg pointed out that the focus of the certification will be on advanced heart failure and the posttransplant setting, not on milder forms of the disease that account for most cases and are usually treated by primary-care physicians and general cardiologists. "Initially there was some concern by other constituencies that we might be overlapping them. But once they understood that this was going to deal with these advanced, complicated patients, that really kind of melted away," he said. "We don't anticipate being the first-line physicians for all of heart failure."

This is a field that has expanded and grown very much ahead of the certification and accreditation processes and really is the singular reason this had to happen.

Other groups representing physicians concerned with cardiac care—including the American College of Cardiology, Heart Rhythm Society, International Society of Heart & Lung Transplantation, and Society of Thoracic Surgeons—"all played important supporting roles in recognizing along with us the vital importance of heart failure as a subspecialty," Greenberg said.

The American Board of Internal Medicine currently offers subspecialty certificates in cardiovascular disease, clinical cardiac electrophysiology, and interventional cardiology under the general certificate for internal medicine. The American Board of Pediatrics offers a subspecialty certificate in pediatric cardiology under the pediatrics general certificate.

The boards in advanced heart failure and transplant cardiology, according to Konstam, will have "extensive proficiency requirements in cognitive and evaluation and management skills" and, as well, will require a certain level of technical proficiency in caring for patients after transplantation and those with left ventricular assist devices.

"It does not include the actual placement of ventricular assist devices, and it does not include the actual placement of things like [implantable defibrillators] and [cardiac resynchronization therapy] devices," he said. "But it does entail expertise and proficiencies in, first of all, referral for those devices; second, care of patients who have those devices; and third, as far as the electrophysiological devices that I mentioned, interrogation of those devices—which is something new for most programs."