Take-Home Messages:

• Medical technology improvements have increased radiation exposure risks to cardiovascular patients.
• Controversy still exists as to whether low doses of ionizing radiation used in cardiovascular care may be associated with an increased lifetime risk of cancer.
• A new white paper promotes patient safety in medical uses of radiation.

Given the high prevalence and mortality associated with cardiovascular disease, timely diagnosis and treatment are crucial. In recent years, this has increasingly involved technology requiring ionizing radiation. According to the National Council on Radiation Protection and Measurements, the collective dose received from medical uses of radiation in the U.S. increased by >600% between 1980 and 2006.

As a result, there has been greater attention to ensuring patient safety in the practice of adult cardiovascular medicine. Although Congress has held hearings to investigate the need to regulate radiation exposure in the clinical setting, many unanswered questions still remain.

Consequently, representatives from cardiovascular imaging societies, private payers, government and nongovernmental agencies, industry, medical physicists, and patient representatives met in 2011 to better define the issues and needs around patient radiation safety in cardiovascular imaging and to develop an action plan to guide future efforts. The result was a white paper published online in late March 2012.

The “think tank” included the ACC, Duke University Clinical Research Institute, AHA, the American College of Radiology, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Nuclear Medicine. The chair of the group was former ACC President Pamela S. Douglas, MD, MACC.

Recommendations

The biological effects of ionizing radiation fall into two broad categories. 

• Deterministic effects predictably occur above certain thresholds of absorbed dose to a specific tissue and include skin erythema, epilation, and possibly even direct cardiac toxicity.
• Stochastic effects are those in which radiation causes damage that may result in a malignancy, usually at a much later time.

The think tank organizers identified four broad categories for improving radiation safety in adult CV patients:

• Quantifying the estimated stochastic risks of low-dose radiation associated with cardiovascular imaging and therapeutic procedures.
• Measuring and reporting radiation dose in cardiovascular imaging and procedures.
• Minimizing radiation dose for single episodes of care and across entire systems of care.
• Educating and communicating with multiple groups to increase awareness and achieve goals in minimizing exposure.

The group admitted that – at least at the present time – the infrastructure required to support dose assessment for quality improvement purposes is not in place. The needs range from standardization of terminology to adjustments in equipment capabilities to automatically track exposure, patient parameters, and dose during clinical workflow.

Careful patient selection and avoidance of inappropriate testing and procedures including use of ACCF appropriate use criteria is another important recommendation. Another important strategy is balancing the requirement to effectively guide each episode of care with the need to minimize exposure.

Strategies recommended to minimize radiation dose include:

• Education to include mandatory annual online training for basic radiation safety techniques of healthcare providers involved in the ordering or performance of medical testing using ionizing radiation and board certification examinations.
• Quality Metrics: Public reporting of quality metrics including appropriateness of testing, use of dose minimization strategies, objective image quality assessments, and facility-level radiation exposures for common testing categories by local and national standards.
• Common industry/technology standards: Developing common protocols, definitions, parameter settings, and device settings that ensure basic standards are met, while allowing innovation.

Reference

1. Douglas PS, Carr JJ, Cerqueira MD, et al. Developing an action plan for patient radiation safety in adult cardiovascular medicine proceedings from the Duke University Clinical Research Institute/American College of Cardiology Foundation/American Heart Association think tank held on February 28, 2011. Circ Cardiovasc Imaging. 2012: published online before print March 22, 2012.
   

Keywords: Quality Improvement, Safety, Radiation, Ionizing, Patient Selection, Cardiovascular Diseases, Patient Safety, Episode of Care, Radiation Dosage

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