Reidar: Developing the Swedish national certification for echocardiography.

Echocardiography is the most widely used important cardiac investigation and is considered the corner stone diagnostic tool of myocardial and valvular function. Ascertaining optimum quality of the echocardiographic examination is of utmost importance for accurate patient management.

Due to it’s availability, portability, and relatively low cost, echocardiography is increasingly used in not only different settings; in outpatient units, emergency rooms, cardiac wards outside structured echocardiographic laboratories, but also by increasing number of different specialities, cardiology, emergency medicine, anesthesiology, and clinical physiology.

In Sweden echocardiography has been developed mainly within the speciality of clinical physiology, it has recently attracted cardiology trainees and has now become a recognized speciality in Sweden, Denmark and Finland.

The European Society of Cardiology and its largest subsidiary body, the European Association of Cardiovascular Imaging started a certification programme in 2004, its take up in Sweden has been minimal because of a number of reasons: Firstly, it is not mandatory and examinations take place just once a year at an annual congress which requires costly travel. Secondly, the practical element of the examination is logistically challenging where specificaly collecting the 250 cases to be sent to the committee for assessment has created an administrative workload which can be very challenging for the candidate. Thirdly, the European examination is in English, which is often an additional barrier, at least for some of the echocardiographic practitioners.

EACVI has recognized the need for a wider acceptance of a certification of echocardiography, both on a national and European level, and is currently discussing a plan for facilitation of the exam by possible recognition of a national practical exam to be accepted as a part of the EACVI exam.

For these reasons, the Swedish Working Group of Echo (SWGE) has been mandated by the Swedish Heart Association (SHA) to design a national certification system for transthoracic echocardiography, with the intention of developing a unified system during 2015. The voting members of the SHA included various cardiovascular related healthcare professionals in Sweden, specifically cardiology; thoracic surgery, anesthesiology and radiology; and clinical physiology. Both the SWGE and the SHA are keen to ensure that the curriculum is consistent with that of the EACVI, so that candidates will acquire skills recognized across the continent. Currently, the SWGE is in discussions with EACVI for the latter to recognize the recently proposed echocardiography national certification process.

Competence in practicing echocardiography will be assessed in two stages: theoretical and practical.

Theoretical Exam

The theory exam will be conducted in the swedish language and will form the first step of the certification process. It consists of four components.

  1. To enter the programme, candidates are expected to have completed at least three and preferably six months of education and training at one of the well established national Echocardiography Departments. Such lab should be staffed with a renouned team in the field.

  2. In conjunction, candidates will be expected to access the EACVI syllabus ( and the SWG syllabus (, and to study these in their own time. While the broad content of the two syllabuses is similar, there are few difference in the areas of emphasis between them. The latter emphasizes, the importance of the need for patient referral for other investigations, such as stress echocardiography, rather than detailed knowledge of these specialized techniques.

  3. In parallel, candidates are expected to adapt to the culture of frequent self-testing using an automated online questionnaire produced by the SWGE, and which calibrate according to the candidate’s experience and then tailor progressive questions according to the candidate’s ability. Ultimately, candidates will be expected to achieve scores of at least 70% of the total mark. The system is designed to recognize the success level of 70% as corresponding to five years of working experience in the field of Doppler echocardiography.

  4. Finally, the echocardiography syllabus will be delivered on a two day course before/during the annual meeting of the Swedish Heart Association Society, in order to discuss difficult issues and adequately explain any potentially unclear issues in the scientific and practice of echocardiographic techniques in different cardiac diseases.

Practical Exam

Some months later, the successful candidates will be invited to proceed to the practical echocardiography examination day. This day will consist of two echo examinations performed by the candidate who will be required to write and submit a full report. The supervising examiner will also conduct echocardiographic examinations of the same patients as a reference, against which the candidates study will be assessed. The candidate will also be asked to assess some other standard cases with different pathologies and to give opinion on the benefit of echocardiography in the management of such cases.


Successful candidates will be granted a certificate of competence in echocardiography from the Swedish Heart Association.

A certificate is proposed to be granted for five year in concordance with EACVI recommendations, and a re-certification is proposed to be granted based on a written proof for performing a minimum of 100 TTE examinations/year during the five year period.

Current Status

The online test has a growing library of questions, currently around 100, with an ultimate goal of five times that number. This has been used by over 100 echocardiographers to date.

The plans for the programme and the course is near completion and will be sent to the SHA for review during October 2014. Twenty reference labs have indicated a wish to join the programme.

A test course is scheduled for April 2015 in Orebro in conjunction with the Swedish Cardiovascular Annual Conference (Spring-meeting).

Copyright (c) 2015 R Winter

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