The appropriate and justified use of medical radiation in cardiovascular imaging: a position document of the ESC Associations of Cardiovascular Imaging, Percutaneous Cardiovascular Interventions and Electrophysiology.
[en] The benefits of cardiac imaging are immense, and modern medicine requires the extensive and versatile use of a variety of cardiac imaging techniques. Cardiologists are responsible for a large part of the radiation exposures every person gets per year from all medical sources. Therefore, they have a particular responsibility to avoid unjustified and non-optimized use of radiation, but sometimes are imperfectly aware of the radiological dose of the examination they prescribe or practice. This position paper aims to summarize the current knowledge on radiation effective doses (and risks) related to cardiac imaging procedures. We have reviewed the literature on radiation doses, which can range from the equivalent of 1-60 milliSievert (mSv) around a reference dose average of 15 mSv (corresponding to 750 chest X-rays) for a percutaneous coronary intervention, a cardiac radiofrequency ablation, a multidetector coronary angiography, or a myocardial perfusion imaging scintigraphy. We provide a European perspective on the best way to play an active role in implementing into clinical practice the key principle of radiation protection that: 'each patient should get the right imaging exam, at the right time, with the right radiation dose'.
Disciplines :
Cardiovascular & respiratory systems
Author, co-author :
Picano, Eugenio
Vano, Eliseo
Rehani, Madan M.
Cuocolo, Alberto
Mont, Lluis
Bodi, Vicente
Bar, Olivier
Maccia, Carlo
Pierard, Luc ; Université de Liège - ULiège > Département des sciences cliniques > Cardiologie - Pathologie spéciale et réhabilitation
Sicari, Rosa
Plein, Sven
Mahrholdt, Heiko
Lancellotti, Patrizio ; Université de Liège - ULiège > Département des sciences cliniques > Imagerie cardiaque fonctionnelle par échographie
The appropriate and justified use of medical radiation in cardiovascular imaging: a position document of the ESC Associations of Cardiovascular Imaging, Percutaneous Cardiovascular Interventions and Electrophysiology.
Picano E. Sustainability of medical imaging. Education and debate. BMJ 2004;328: 578-580
Mettler FA Jr, Bhargavan M, Faulkner K, Gilley DB, Gray JE, Ibbott GS, Lipoti JA, Mahesh M, McCrohan JL, Stabin MG, Thomadsen BR, Yoshizumi TT. Radiologic and nuclear medicine studies in the United States and worldwide: Frequency, radiation dose, and comparison with other radiation sources-1950-2007. Radiology 2009;253:520-531
Picano E, Vañó E. The radiation issue in cardiology: The time for action is now. Cardiovasc Ultrasound 2011;9:35
Vañó E, González L, Guibelalde E, Fernández JM, Ten JI. Radiation exposure to medical staff in interventional and cardiac radiology. Br J Radiol 1998;71:954-960
Linet MS, Kim KP, Miller DL, Kleinerman RA, Simon SL, Berrington De Gonzalez A. Historical review of occupational exposures and cancer risks in medical radiation workers. Radiat Res 2010;174:793-808
Correia MJ, Hellies A, Andreassi MG, Ghelarducci B, Picano E. Lack of radiological awareness among physicians working in a tertiary care cardiological centre. Int J Cardiol 2005;103:307-311
Einstein AJ, Tilkemeier P, Fazel R, Rakotoarivelo H, Shaw LJ; American Society of Nuclear Cardiology. Radiation safety in nuclear cardiology-current knowledge and practice: Results from the 2011 American Society of Nuclear Cardiology member survey. JAMA Intern Med 2013;173:1021-1023
Berrington De González A, Darby S. Risk of cancer from diagnostic X-rays: Estimates for the UK and 14 other countries. Lancet 2004;363:345-351
Patel MR, Spertus JA, Brindis RG, Hendel RC, Douglas PS, Peterson ED,Wolk MJ, Allen JM, Raskin IE; American College of Cardiology Foundation. ACCF proposed method for evaluating the appropriateness of cardiovascular imaging. J Am Coll Cardiol 2005;46:1606-1613
Gibbons RJ, Miller TD, Hodge D, Urban L, Araoz PA, Pellikka P, McCully RB. Application of appropriateness criteria to stress single-photon emission computed tomography sestamibi studies and stress echocardiograms in an academic medical center. J Am Coll Cardiol 2008;51:1283-1289
Mettler FA. Radiological protection education in medicine an essential but often missing element. Ann ICRP 2009;39:3-4
Authors on behalf of ICRP, Stewart FA, Akleyev AV, Hauer-Jensen M, Hendry JH, Kleiman NJ, Macvittie TJ, Aleman BM, Edgar AB, Mabuchi K, Muirhead CR, Shore RE, Wallace WH. ICRP statement on tissue reactions and early and late effects of radiation in normal tissues and organs-threshold doses for tissue reactions in a radiation protection context. Ann ICRP 2012;41:1-322. doi:10.1016/j.icrp.2012.02.001
Rehani MM, Srimahachota S. Skin injuries in interventional procedures. Radiat Prot Dosimetry 2011;147:8-12
Rehani MM, Vano E, Ciraj-Bielac O, Kleiman NJ. Radiation and cataract. Radiat Prot Dosimetry 2011;147:300-304
UNSCEAR 2008 Report: Sources and effects of ionizing radiation. Vol. I. http://www.unscear.org/docs/reports/2008/09-86753-Report-2008-Annex-A.pdf (9 September 2013)
Radiation Protection 125. Low dose ionizing radiation and cancer risk. Luxembourg, 2001. http://ec.europa.eu/energy/nuclear/radiation-protection/doc/ pub lication/125.pdf (9 September 2013).
The 2007 recommendations of the International Commission on Radiological Protection. ICRP Publication 103. Ann ICRP 2007;37:1-34
Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII, Phase 2. http://www.nap.edu/openbook.php?Isbn=030909156X (15 July 2013).
Mathews JD, Forsythe AV, Brady Z, Butler MW, Goergen SK, Byrnes GB, Giles GG, Wallace AB, Anderson PR, Guiver TA, McGale P, Cain TM, Dowty JG, Bickerstaffe AC, Darby SC. Cancer risk in 680 000 people exposed to computed tomography scans in childhood or adolescence: Data linkage study of 11 million Australians. BMJ 2013;346:f2360
Bedetti G, Botto N, Andreassi MG, Traino C, Vano E, Picano E. Cumulative patient effective dose in cardiology. Br J Radiol 2008;81:699-705
Kaul P, Medvedev S, Hohmann SF, Douglas PS, Peterson ED, Patel MR. Ionizing radiation exposure to patients admitted with acute myocardial infarction in the United States. Circulation 2010;122:2160-2169
Einstein AJ, Weiner SD, Bernheim A, Kulon M, Bokhari S, Johnson LL, Moses JW, Balter S. Multiple testing, cumulative radiation dose, and clinical indications in patients undergoing myocardial perfusion imaging. JAMA 2010;304:2137-2144
Smith-Bindman R, Lipson J, Marcus R, Kim KP, Mahesh M, Gould R, Berrington De González A, Miglioretti DL. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med 2009;169:2078-2086
Fiechter M, Stehli J, Fuchs TA, Dougoud S, Gaemperli O, Kaufmann PA. Impact of cardiac magnetic resonance imaging on human lymphocyte DNA integrity. Eur Heart J 2013;34:2340-2345
Mettler FA Jr, HudaW, Yoshizumi TT, Mahesh M. Effective doses in radiology and diagnostic nuclear medicine: A catalog. Radiology 2008;248:254-263
The Administration of Radioactive Substances Advisory Committee (ARSAC), 2006. http://www.arsac.org.uk/(15 July 2013)
Gaemperli O, Saraste A, Knuuti J. Cardiac hybrid imaging. Eur Heart J Cardiovasc Imaging 2012;13:51-60
Einstein AJ, MoserKW, Thompson RC, Cerqueira MD, Henzlova MJ. Radiation dose to patients from cardiac diagnostic imaging. Circulation 2007;116:1290-1305
Cerqueira MD, Allman KC, Ficaro EP, Hansen CL, Nichols KJ, Thompson RC, Van Decker WA, Yakovlevitch M. Recommendations for reducing radiation exposure in myocardial perfusion imaging. J Nucl Cardiol 2010;17:709-718
Ghoshhajra BB, Engel LC, Major GP, Goehler A, Techasith T, Verdini D, Do S, Liu B, Li X, Sala M, Kim MS, Blankstein R, Prakash P, Sidhu MS, Corsini E, Banerji D, Wu D, Abbara S, Truong Q, Brady TJ, Hoffmann U, Kalra M. Evolution of coronary computed tomography radiation dose reduction at a tertiary referral center. Am J Med 2012;125:764-772
Christner JA, Kofler JM, McCollough CH. Estimating effective dose for CT using dose-length product compared with using organ doses: Consequences of adopting International Commission on Radiological Protection Publication 103 or dual-energy scanning. AJR Am J Roentgenol 2010;194:881-889
Geleijns J, Joemai RM, Dewey M, De Roos A, Zankl M, Cantera AC, Artells MS. Radiation exposure to patients in a multicenter coronary angiography trial (CORE 64). AJR Am J Roentgenol 2011;196:1126-1132
Signorotto P, del Vecchio A, Montorfano M, Maisano F, Giagnorio M, Bellanca R, Colombo A, Calandrino R. Dosimetric data and radiation risk analysis for new procedures in interventional cardiology. Radiat Prot Dosimetry 2010;142:201-208
Suzuki S, Furui S, Yamakawa T, Isshiki T,Watanabe A, Iino R, Kidouchi T, Nakano Y. Radiation exposure to patients' skin during cardiac resynchronization therapy. Europace 2009;11:1683-1688
Panuccio G, Greenberg RK, Wunderle K, Mastracci TM, Eagleton MG, DavrosW. Comparison of indirect radiation dose estimates with directly measured radiation dose for patients and operators during complex endovascular procedures. J Vasc Surg 2011;53:885-894.e1
Bacher K, Bogaert E, Lapere R, DeWolf D, Thierens H. Patient-specific dose and radiation risk estimation in pediatric cardiac catheterization. Circulation 2005;111: 83-89
Rehani M, Ciraj Bjekac O, Vano E, Miller DL, Walsh S, Giordano BD, Perslinden J. Radiological protection in fluoroscopically guided procedures performed outside the imaging department. ICRP Publication 117. Ann ICRP 2010;40:1-102
Karambatsakidou A, Sahlgren B, Hansson B, Lidegran M, Fransson A. Effective dose conversion factors in paediatric interventional cardiology. Br J Radiol 2009;82: 748-755
Heidbuchel H, Wittkampf F, Vano E, Ernst S, Schilling R, Picano E, Mont L. Practical ways to reduce radiation dose for patients and staff during device implantations and electrophysiological procedures. EHRA Position Paper. Europace 2013; doi:10.1093/europace/eut409
Venneri L, Rossi F, Botto N, Andreassi MG, Salcone N, Emad A, Lazzeri M, Gori C, Vano E, Picano E. Cancer risk from professional exposure in staff working in cardiac catheterization laboratory: Insights from the National Research Council's Biological Effects of Ionizing Radiation VII Report. Am Heart J 2009;157:118-124
Vaño E, Gonzalez L, Fernandez JM, Alfonso F, Macaya C. Occupational radiation doses in interventional cardiology: A 15-year follow-up. Br J Radiol 2006;79:383-388
Vañó E. Radiation exposure tocardiologists:howit could be reduced. Heart 2003;89: 1123-1124
Ait-Ali L, Andreassi MG, Foffa I, Spadoni I, Vano E, Picano E. Cumulative patient effective dose and acute radiation-induced chromosomal DNA damage in children with congenital heart disease. Heart 2010;96:269-274
Latini G, Dipaola L, Mantovani A, Picano E. Reproductive effects of low-to-moderate medical radiation exposure. Curr Med Chem 2012;19:6171-6177
Leung AN, Bull TM, Jaeschke R, Lockwood CJ, Boiselle PM, Hurwitz LM, James AH, McCullough LB, Menda Y, Paidas MJ, Royal HD, Tapson VF, Winer-Muram HT, Chervenak FA, Cody DD, McNitt-Gray MF, Stave CD, Tuttle BD; ATS/STR Committee on Pulmonary Embolism in Pregnancy. An official American Thoracic Society/Society of Thoracic Radiology clinical practice guideline: Evaluation of suspected pulmonary embolism in pregnancy. Am J Respir Crit Care Med 2011;184:1200-1208
ShawP, Duncan A, Vouyouka A, Ozsvath K. Radiation exposure and pregnancy. J Vasc Surg 2011;53:28S-34S.
Picano E. Informed consent and communication of risk from radiological and nuclear medicine examinations: How to escape from a communication inferno. Education and debate. BMJ 2004;329:849-851
Terranova G, FerroM, Carpeggiani C, RecchiaV, Braga L, Semelka RC, Picano E. Low quality and lack of clarity of current informed consent forms in cardiology: How to improve them. JACC Cardiovasc Imaging 2012;5:649-655
U.S. Food and Drug Administration. White Paper: Initiative to reduce unnecessary radiation exposure from medical imaging, April 2010. http://www.fda.gov/Radiation-EmittingProducts/RadiationSafety/ RadiationDoseReduction/ucm199994.htm (15 July 2013).
