The Future of Cardiovascular Subspecialty Training

Figure 1. Illustration of Cardiovascular Fellow Evaluation Over Time Using Milestones Data Over this 5-year period, national milestone ratings for third year cardiovascular disease fellows increased across all six ACGME competency domains. The greatest gains were observed in medical knowledge, patient care, and interpersonal and communication skills, with fellows in 2023 to 2024 approaching or exceeding milestone level 4.0 in these areas. Improvements were also noted in the remaining domains, indicating broad-based advancement in fellow development. These findings suggest continued national growth in competency attainment and progression toward readiness for unsupervised practice at fellowship completion.

Figure 2. Illustration of Cardiovascular Fellow Evaluation Using Predicted Performance Value Data Predicted performance value (PPV) distributions across cardiovascular disease fellowship subcompetencies at second-year mid-year, second-year year-end, and third-year mid-year assessments. PPV values represent the percentage of fellows performing at or below selected milestone thresholds across patient care (PC), medical knowledge (MK), Systems-Based Practice (SBP), Professionalism (PROF), and interpersonal and communication skills (ICS) subcompetencies. Higher PPV values indicate a larger proportion of fellows remaining below the specified milestone level. The largest increases were observed in patient care and professionalism subcompetencies, reflecting greater variability in developmental progression and identifying areas that may benefit from targeted educational support.

Figure 3. Training Requirements in Echocardiography Adapted with permission from Ryan, T, Berlacher, K, Lindner, J. et al. COCATS 4 Task Force 5: Training in Echocardiography. J Am Coll Cardiol. 2015;65(17):1786-1799. This figure displays the COCATS requirements in terms of both time in training and number of procedures required to achieve different levels of certification in echocardiography. The current training paradigm requires not only a number of studies interpreted, but also a fixed number of months of training, with that inflexibility disadvantaging learners who gain proficiency in echocardiography in a shorter period of time than required. ∗Typical duration assuming acceptable progress toward milestones and demonstrated competency. Add = additional; TTE = transthoracic echocardiography.

Figure 4. Data Showing That by the Second Year of Fellowship, Most Cardiovascular Disease Fellows Have Achieved Near-Independent Practice National data from the ACGME Milestones National Report 2025 for cardiovascular disease fellows showing the cumulative proportion of fellows assessed at or below specified milestone levels at each evaluation period. PPV tables provide national reference distributions that programs may use to contextualize Clinical Competency Committee assessments and fellow developmental progression relative to national norms. For 2025, cardiovascular disease fellows demonstrated substantial progression toward near-independent practice by the second year of fellowship, supporting individualized learning opportunities in advanced subspecialty areas such as interventional cardiology and electrophysiology. Lev = level; PC = patient care; PPV = predicted performance value.

Central Illustration. Reimagining the Future Cardiovascular Subspecialty Training Scientific advances in cardiovascular (CV) medicine have led to an increase in CV subspecialization, but training paradigms have not kept up with those advances. Inability of the current model of CV subspecialty training to meet the needs of trainees and the healthcare community have led to a shortage of some CV subspecialists and inadequate CV subspecialty expertise in some regions. Remedies to these gaps include current pilots of 2 + 2 models (2 years general cardiology, 2 years advanced fellowship training) and competency-based advancement. Future paradigms that may improve the current training model include shortening general cardiology training to 2 years (2 + 1 model) and adapting modular, competency-based training to enhance the ability to obtain CV subspecialty expertise during general cardiology fellowship (level II COCATS certification), while expanding 2 + 2 training models to encompass overlapping CV subspecialties (e.g. Advanced Heart Failure and Cardiac Transplantation and Critical Care). COCATS = Core Cardiology Training Symposium.

Figure 5. Demonstration of Third-Year Fellow Competency in Cardiovascular Subspecialties Using the In-Training Examination Line graph illustrating annual percent-correct scores for the Heart Failure and Pulmonary Hypertension content domains on the cardiovascular disease in-training examination (ITE) from 2019 through 2024. Percent-correct scores increased overall during the study period, with the greatest improvement observed in pulmonary hypertension, whereas heart failure performance remained relatively stable following a temporary decline. The average score across both domains increased from approximately 70% to 75% over the 6-year period, revealing a high level of competency in these two cardiovascular subspecialties, and supporting potential level II subspecialty certification during fellowship.

Figure 6. Potential Subspecialty Certification Pathways for Expertise in Advanced Heart Failure and Transplant Cardiology Multiple pathways to achieve cardiovascular subspecialty skills and certification should exist. Here we propose pathways for Advanced Heart Failure and Transplant Cardiology certification, emphasizing that level II certification is an acceptable certification, and also reinforcing that practice-based pathways to certification should exist. The desired result would be an increase in the number of cardiologists able to provide high quality CV subspecialty care (both level II and level III). ABIM = American Board of Internal Medicine; ACHD = adult congenital heart disease; AHFTC = Advanced Heart Failure and Transplant Cardiology; Cardio-OB = cardio-obstetrics; CV = cardiovascular; HF = heart failure.

Figure 7. A Schematic for Combined Advanced Heart Failure (Advanced Heart Failure and Transplant Cardiology) and Critical Care Training Adapted with permission from Carnicelli et al, Critical Care Enrichment During Advanced Heart Failure Training J Am Coll Cardiol 2023. One proposed pathway toward dual AHFTC and Critical Care certification over 1 year. Such a certification pathway would be reinforced by modular training (eg 4-week blocks of critical care) in conjunction with competency based training (eg ventilator management, chest tube placement).

Figure 8. Integrated ACHD and Advanced Heart Failure and Transplant Cardiology Training Adapted from Marshall, Paving the Way for Integrated Advanced Heart Failure and Adult Congenital Heart Disease Training, JACC Advances 2025. A detailed curricular pathway for integrated ACHD and AHFTC training, highlighting the concept of competency-based training coupled with longitudinal clinical experiences. FIT = fellow in training; other abbreviations as in Figure 6.