Miriam Norman, Royal Hobart Hospital, Tas
Editor’s Note: This opinion piece offers insights from a successful exam candidate. There are many ways to prepare, and PiCSA encourages seeking guidance from a range of sources to find what works best for you.
PiCSA considers credentialing in Cardiac Devices to be at the same advanced level as Electrophysiology and Echocardiography. The absence of an Australian qualification in pacing does not diminish the depth of knowledge, skill, or expertise required. PiCSA recognises the need for more resources and looks forward to greater support in the future.
The most common certification for Australian cardiac device specialists is currently the International Board of Heart Rhythm Examiners (IBHRE) Certified Cardiac Device Specialist (CCDS) exam.
The exam (along with a few other international options) is officially endorsed by Professionals in Cardiac Sciences Australia (PiCSA) and allows for local registration as an accredited cardiac device specialist with the Australian Council of Clinical Physiologists (https://theaccp.org.au). The full list of recognised qualifications is found in PiCSA’s “Australian Guidelines for Entry and Practice in the Field of Cardiac Physiology” (https://picsa.org.au/about/#core-documents).
Individual cardiac physiologists may find themselves working and learning without an on-site credentialed cardiac device educator. Having been in that situation myself when I qualified in 2012, I know how challenging it can be. That’s why I wanted to share some valuable resources to help you build your knowledge and prepare for the exam. Even without experienced colleagues around, it is possible to achieve an advanced level of understanding and get yourself qualified.
Whilst I mostly studied using books and guideline documents, there are now even better books, and some excellent online resources. Start with basic content and work your way up. When you get to the heavy-weight textbooks, it is time to augment your study with question-based learning.
Why bother getting qualified?
- Not being qualified undermines the profession’s reputation. Competency assessment is essential for patient safety in advanced cardiac physiology, and employers increasingly value certification. This exam validates your expertise in cardiac devices, with recognition both locally and internationally.
Eligibility:
- Access to the exam is conditional on current employment working with cardiac devices, and an appropriate background. Success in the exam requires substantial practical hands-on experience and will be easiest for individuals with a good tertiary academic background in physiology and biotechnology. You don’t have to work with every brand of device to pass the exam.
Exam Format:
- It’s a computer-based 4 hour exam consisting
of 200 multiple-choice questions, conducted annually via Prometric test centres around Australia and overseas. Refer to the IBHRE website for more details: https://ibhre.org/ap/ccds.
Recertification:
- IBHRE CCDS credential is not indefinite. Professionals must recertify by taking the comprehensive exam periodically, or by active participation in the IBHRE’s C3 continuing professional development program. Maintenance of certification is a requirement for ongoing recognition at the highest level of qualification on the ACCP registry.
Study Tips for Cardiac Device Learning:
Choose the Right Level of Textbook (or other study material)
I always recommend that if a book is hard to concentrate on, switch to an easier one. Don’t waste time struggling if you are not learning. I still regularly go back to basics to reinforce foundational learning.
Keep Your Resources Up to Date
Cardiac devices evolve rapidly-replace old textbooks or guidelines as soon as new editions/versions are available.
Use Questions as Study Tools
- Practice questions help reinforce knowledge and make key concepts stick.
- They encourage looking things up, which deepens understanding.
- They expose you to all device brands, even those you might not encounter in daily practice.
Books I Recommend (starting simple):
1. ECG Books:
- ECG Workout: Exercises in Arrhythmia Interpretation Jane Huff (2022). ECG Workout: Exercises in Arrhythmia Interpretation (8th ed.). Wolters Kluwer.
- Rapid Interpretation of EKGs: Dubin’s Classic, Simplified Methodology for Understanding EKGs Dale Dubin (2022). Rapid Interpretation of EKGs: An Interactive Course (7th ed.). Cover Publishing Company.
2. Introduction to Pacing:
- Practical Guide to Cardiac Pacing H. Weston Moses & James C. Mullin (2021). Practical Guide to Cardiac Pacing (6th ed.). Wolters Kluwer.
This is my top reading recommendation for cardiology registrars who want to confidently discuss cardiac device issues with subject matter experts. It’s concise, easy to digest, and explains fundamental pacing concepts in impressively simple language.
For visual learners, several of my colleagues recommend the following text:
- Cardiac Pacemakers and Resynchronization Step by Step: An Illustrated Guide S. Serge Barold, Roland X. Stroobandt, Alfons F. Sinnaeve (2010). Cardiac Pacemakers and Resynchronization Step by Step: An Illustrated Guide (2nd ed). Wiley-Blackwell.
3. Nuts and Bolts Series:
- The Nuts and Bolts of Cardiac Pacing Tom Kenny (2014). The Nuts and Bolts of Cardiac Pacing (2nd ed.). Wiley-Blackwell.
- The Nuts and Bolts of Paced ECG Interpretation Tom Kenny (2009). The Nuts and Bolts of Paced ECG Interpretation (1st ed.). Wiley-Blackwell.
- The Nuts and Bolts of ICD Therapy Tom Kenny (2015). The Nuts and Bolts of ICD Therapy (2nd ed.). Wiley-Blackwell.
- The Nuts and Bolts of Cardiac Resynchronization Therapy Tom Kenny (2015). The Nuts and Bolts of Cardiac Resynchronization Therapy (2nd ed.). Wiley-Blackwell.
4. Major (Heavy-weight) textbooks:
- Cardiac Pacing, Defibrillation and Resynchronization: A Clinical Approach Davis L. Hayes, Samuel J. Asirvatham, Paul A. Friedman (2021). Cardiac Pacing, Defibrillation and Resynchronization: A Clinical Approach (4th ed.). Wiley.
I strongly recommend reading the entire book, but I suggest starting with the interesting chapters first (“implant complications” for example). If it puts you to sleep, go back to an easier text, pick a different chapter, or find yourself some questions to practice.
If Hayes is starting to get easy, and you’ve read it 3 times already, consider attempting the following book:
- Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy Kenneth A. Ellenbogen, Bruce L. Wilkoff, G. Neal Kay, Chu Pak Lau, Angelo Auricchio (2016). Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy (5th ed.). Elsevier.
This text is the globally recognised gold-standard authoritative text on cardiac devices. Incredibly in-depth, it makes for challenging reading. My attempts to get through it cover to cover failed miserably (instant anaesthetic), so I use it more as an expert reference when I need the fine print on specific topics.
5. Understanding the different brands’ algorithms:
- Pacemakers and Implantable Cardioverter Defibrillators: An Expert’s Manual Amin Al-Ahmad, Kenneth A. Ellenbogen, Andrea Natale, Paul J. Wang (2010). Pacemakers and Implantable Cardioverter Defibrillators: An Expert’s Manual (1st ed.). Cardiotext Publishing.
This manual is one of my favourites—it explains the different device features and algorithms across major manufacturers. The content is now a bit outdated, but it is still a valuable resource. I’ve used it several times as a starting point for creating my own up-to-date cheat sheets for quick reference in clinic.
6. Question based learning:
- A Case-Based Approach to Pacemakers, ICDs, and Cardiac Resynchronization: Questions for Examination Review and Clinical Practice [Volumes 1, 2 & 3]
Paul A. Friedman, Melissa A. Rott, Anita Wokhlu, Samuel J. Asirvatham, David L. Hayes (2013, 2016). A Case-Based Approach to Pacemakers, ICDs, and Cardiac Resynchronization: Questions for Examination Review and Clinical Practice (3-Volume Set). Cardiotext Publishing.
These 3 volumes offer an extensive collection of case-based questions and practical insights, following the Mayo Clinic approach, making them invaluable for both exam preparation and real-world clinical decision-making. I have found it very useful to be able to reference it in similar scenarios and state, “Here’s what the Mayo Clinic would recommend”.
- CRM Exam Review 2011 – 2 Volume Set (The Cardiac Device Exam Test & Supplemental Materials) Mark Sweesy, Jim Holland (2011). CRM Exam Review 2011 – 2 Volume Set (The Cardiac Device Exam Test & Supplemental Materials).
Sadly this 2 volume set is now out of print, however, consider the following duo from the same authors:
- Heart Rhythm Device Follow-up: The Basics (Volume 1) Mark E. Sweesy, James P. Holland (2016). Heart Rhythm Device Follow-up: The Basics (1st ed.). Cardiotext Publishing.
- Heart Rhythm Device Follow-up: Case Studies (Volume 2) Mark E. Sweesy, James P. Holland (2016). Heart Rhythm Device Follow-up: Case Studies (1st ed.). Cardiotext Publishing.
These books are the closest Australians can get to the Arrhythmia Technologies Institute’s IBHRE CCDS exam prep course (which is only available to citizens of the USA). The books are far more affordable than the course, which costs over $50,000 AUD.
Other Resources:
- The IBHRE CCDS recommended reading list: https://ibhre.org/exam-resources/study-tips-reading-lists/cardiac-rhythm-device-reading-list.
- HRS consensus guidelines https://www.guidelinecentral.com/guidelines/ (try filtering for organisation “Heart rhythm society” and topic “CIED”). You may wish to print out the relevant guidelines and make up your own physical book. These guidelines are just as important as HAYES, and they are written by the same organisation that oversees the exam.
- The IBHRE Cardiac Device Education & Self-Assessment Course (https://ibhre.org/CDESA). Having personally contributed to earlier versions of this online course, I highly recommend investing to access the material (it currently costs about $630 AUD). The questions are invaluable for repeated practice, and it features useful additions beyond the standard IBHRE recommended reading. Brought to you by the same organisation that writes the exam, so it is a VERY motivating resource.
- Wikipedia contains extremely well written entries on the “cardiac action potential”, and “antiarrhythmic agents”.
- PiCSA members can also access a library of relevant educational newsletter articles and videos on the members section of our website (https://picsa.org.au/) and can (with adequate notice) assist with mentoring and customised training events.
- Vendor Educational Resources: Vendor educational websites offer free, continually evolving resources, especially valuable for learning about brand-specific features. Below are links to the currently available manufacturer-hosted educational sites. (Note: At the time of writing, Abbott does not offer education in this format).
Additionally, manufacturers may provide one-on-one or group “product support” training, which can be indispensable. While some of the most experienced educators in our profession are industry-employed specialists, I do not recommend relying solely on manufacturers as your primary source of education. A well-rounded approach to learning is key.
Biotronik | |
Boston | |
Medtronic | |
Microport |
- Online flash cards: https://www.brainscape.com/learn/ibhre
- Go back and read the Hayes textbook again!
Tips for the Exam Itself:
Take the Computer-Based Testing Tutorial before exam day to familiarise yourself with the format.
It’s a very long exam and can feel a lot like an endurance race. Many people report that their brains start to feel like mush around the 3-hour mark. I personally felt physically ill by the time I finished. If you can push yourself to do some marathon study sessions leading up to the test, that will be good stamina training.
Make sure to get a good night’s sleep before the exam and have a good sustaining meal an hour or so before you start.
When reading each question, use your cursor to highlight the key points. This will help a lot, especially because some questions can be tricky – for example, an ECG or graph may show an obvious issue, but the question might ask about something completely different. You need to really focus on what they’re actually asking. The questions are multiple choice, and striking out obviously incorrect answers will help you focus more on the remaining options. These “markup” tools are great aids for concentration, so make sure to use them.
Since you’re on a time limit, you’ll need to move on from certain questions before you’re entirely satisfied with your answer. Flag these questions so you can return to them when you finish the section and use any remaining time to address the ones you were unsure about.
You’ll also get breaks between the exam sections. TAKE ALL THE BREAKS. Stretch your legs, use the bathroom, grab a snack, hydrate – whatever helps you build stamina. I recommend coming prepared with suitable snacks.
Conclusion:
This document is to assist individuals preparing for the IBHRE exam and is needed because (as of March 2025) there is no local CIED course available to Australian cardiac physiologists (watch this space). PiCSA’s CIED competency standards document (shortly to be released) compliments the certification exam with practical skills assessment criterion and logbook recommendations.
Preparing for the IBHRE exam can be daunting, but with the right strategies and mindset, success is achievable. A mix of structured learning, question-based practice, and hands-on experience is key. Stay updated, seek mentorship, and believe in your ability to master the material. Best of luck—I look forward to seeing more qualified cardiac device specialists in the field!
Don’t forget to update the ACCP registry (www.theaccp.org.au) with your new qualification!
