ESC Statement Cautions Against Radiation Overuse in Cardiac Procedures

Cardiologists need to pay closer attention to patient radiation exposure rates and adequately explain the long-term risks of radiation to patients before performing procedures, according to a European Society of Cardiology (ESC) statement published online January 8, 2014, ahead of print in the European Heart Journal.

Authors led by Luigi P. Badano, MD, of the University of Padua (Padua, Italy), claim that 40% of patient radiology exposure stems from cardiology. They reviewed literature on radiation doses produced by cardiac procedures and summarized the range of estimated radiation exposure for each procedure as well as the associated risk (table 1).

Table 1. Standard Average Reference Doses of Common Cardiac Examinations

 

Equivalent Chest X-Rays

Background
Radiation, years

Diagnostic Electrophysiology Studies

160

1.2

Diagnostic Coronary Angiography

350

2.9

PET F-18 Fluorodeoxyglucose rest (400 MBq, viability)

400

3.3

64-Slice Coronary CTA

750

6.25

PCI

750

6.3


To help facilitate conversations between clinicians and patients about radiation exposure and its inherent risks, the authors recommend appropriate terminology (table 2).

Table 2. Recommended Terminology: Healthy 50 Year Old Mana

 

Additional Lifetime Risk of Fatal and Non-Fatal Cancer

Proposed Risk Term

Chest X-Ray

1 in 1 million

Negligible

Abdominal X-Ray

1 in 100,000 to 1 in 1 million

Minimal

Chest CT

1 in 10,000 to 1 in 1,000

Very Low

PCI

1 in 1,000 to 1 in 100

Low

aRisks are 1.38 higher for women, 4 times higher in children, and half as high in an 80 year old man.

Room for Improvement

In a press release, co-author Eugenio Picano, MD, of the Institute of Clinical Physiology, CNR (Pisa, Italy), reported, “even in the best centers, and even when the income of doctors is not related to number of examinations performed, 30 to 50% of examinations are totally or partially inappropriate according to specialty recommendations. When examinations are appropriate, the dose is often not systematically audited and therefore not optimized, with values which are 2 to 10 times higher than the reference, expected dose.”

Lower doses should be sought going forward, he continued, and many companies are “now successfully fighting a 'dose war'.” The manufacturers that develop better methods of dose reduction “will win in the future global competition,” Dr. Picano added.

Empowering Patients

Stephen Balter, PhD, of Columbia University Medical Center (New York, NY), told TCTMD in a telephone interview that while the paper reflects European practice, the trends and priorities are similar to those seen in the United States. “There is a worldwide drive in the developed world to empower patients in all aspects of healthcare, and this is one example,” he said. “In the United States, patients are becoming increasingly empowered, and it looks like this is pushing that empowerment.”

The main message, Dr. Balter said, comes down to “[knowing] what you’re doing, only [doing] it if you have to, and [letting] your patients know what you’re doing and why you’re doing it.”

The ESC investigators recommend that patients be informed of the estimated ionizing dose before a procedure and the actual dose in writing afterward, if they request it. There have been moves toward making this recommendation law in both Europe and the United States. In Europe, the relevant legislation is the European Directive Euratom law 97/43 though application has been delayed by technical and practical difficulties. In the United States, legislative edicts exist in the states of California, Connecticut, and Texas.

 


Source:
Picano E, Vaño E, Rehani MM, et al. 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. Eur Heart J. 2014;Epub ahead of print.

 

 

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ESC Statement Cautions Against Radiation Overuse in Cardiac Procedures

Cardiologists need to pay closer attention to patient radiation exposure rates and adequately explain the long term risks of radiation to patients before performing procedures, according to a European Society of Cardiology (ESC) statement published online January 8, 2014, ahead
Disclosures
  • Dr. Badano reports serving on the speakers’ bureau of GE Vingmed.
  • Dr. Picano reports being the inventor of a pacemaker licensed to Medtronic.
  • Dr. Balter reports no relevant conflicts of interest.

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