JACC in a Flash | As the utilization of radiation-emitting noninvasive cardiac imaging procedures has increased, concerns about ionizing radiation (for patients and cath lab personnel), inappropriate use, and lack of adherence to quality control have likewise increased.

In a recent symposium, sponsored by the National Institute of Health and National Heart, Lung, and Blood Institute, an international group of cardiologists, radiologists, and radiation physicists gathered to find an answer to the question: "Are current practice patterns aligned with patient-centered imaging quality, particularly those related to radiation safety principles of justification and optimization?" Andrew J. Einstein, MD, PhD, from Columbia University Medical Center and New York-Presbyterian Hospital in New York, and co-authors reported the findings of the symposium in a recent JACC article.

Working in three tracks, participants identified key components of a framework to target critical radiation safety issues for the patient, the laboratory, and the larger population of patients with known or suspected cardiovascular disease. Avoiding unnecessary harm for patients was chief among their concerns, mainly through communication with patients. For instance, the use of ionizing radiation during an imaging procedure should be disclosed to all patients by the ordering physician and reinforced by the performing provider team, using simple, clear language to communicate potential radiation risk. This conversation also provides an opportunity to discuss alternative tests that might not expose the patient to ionizing radiation.

To help patients contextualize radiation dosage, and to help physicians decide when to initiate a decision-making conversation, the symposium proposed the following effective doses:

• 3 mSv: the average annual background level of radiation in the US
• 20 mSv: recommended average annual occupational dose limit for adults
• 50 mSv: single-year occupational dose limit for adults

The symposium focused heavily on improving quality through a focus on laboratory reporting and tracking—particularly in measuring safety, image quality, and diagnostic performance. "The most likely method to reduce population radiation exposure is to minimize test use for referral indications classified as inappropriate or rarely appropriate," Einstein et al. wrote. "That would improve justification for radiation exposure, and thereby foster population-wide reductions in radiation exposure."

"The creation of the patient-centered imaging laboratory that prioritizes patient safety and effectiveness will require sizeable changes to the culture of imaging, which now focuses on volume and efficiency," Dr. Einstein and colleagues commented, and all of these efforts require a continuous, multi-pronged approach. Ultimately, the symposium members settled on three basic principles to guide patient-centered imaging and exposure to ionizing radiation:

• Justification Principle: Benefits and risks of all testing options should be compared, and if an exposure cannot be justified, the test should not be performed.
• Optimization Principle: All doses due to medical exposure must be kept as low as reasonably achievable.
• Responsibility Principle: Both the referrer and the imager are responsible for justification of the test involving exposure to ionizing radiation.

In an accompanying editorial, Lewis Wexler, MD, commented on the need for patient-centered imaging guidelines, asking "How can the physician have a productive conversation about the risks of ionizing radiation with a patient?" In addition to a lack of scientific evidence demonstrating significant risk from any of these diagnostic procedures in adult patients, patients may also have an unrealistic fear of radiation without any rational basis, perhaps fueled by articles in the press and given voice in the media, Dr. Wexler added, again highlighting the need for patient education.

"Taken together, these suggestions are vital to the patient-centered health care the authors favor, and will prepare physicians to have the necessary conversations with diverse patient groups," Dr. Wexler concluded. "Patients deserve a conversation that honors their concerns and presents them with evidence in a manner that is understandable to help them share in the decision to undergo a cardiac imaging test that is best suited to elucidate the nature of their problem and that puts their concerns in perspective."

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Einstein AJ, Berman DS, Min JK, et al. J Am Coll Cardiol. 2014;63:1480-9.
Wexler L. J Am Coll Cardiol. 2014;63:1490-2.

Keywords: National Heart, Lung, and Blood Institute (U.S.), Quality Control, Radiation, Ionizing, Patient Safety, Risk Assessment, Radiation Dosage, CardioSource WorldNews, ACC Publications

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