AHA Statement Urges Radiation Education for All Clinicians and Patients

Better education efforts are needed to improve knowledge about radiation exposure among both referring clinicians and those who perform cardiovascular imaging procedures, according to a scientific statement from the American Heart Association (AHA). Endorsed by 5 medical societies and published online September 29, 2014, ahead of print in Circulation, the statement also urges all “stakeholders” across disciplines to work together in setting standards for training and ongoing education.

“Education regarding the benefits and risks of imaging and the principles of radiation safety is required for all clinicians in order for them to be able to use imaging optimally,” write Reza Fazel, MD, MSc, of Beth Israel Deaconess Medical Center (Boston, MA), and colleagues. “Empowering patients with knowledge of the benefits and risks of imaging will facilitate their meaningful participation in decisions related to their health care, which is necessary to achieve patient-centered care.”

The document outlines 3 key approaches to enhancing radiation safety in medical imaging—education, justification, and optimization.

According to Dr. Fazel and colleagues, studies on both radiologists and nonradiologists have consistently shown “a lack of adequate awareness among physicians of basic concepts related to radiation exposure from medical imaging.” In a study of clinicians caring for patients undergoing computed tomography (CT) scans for abdominal and flank pain, for example, fewer than half of radiologists and only 9% of emergency department physicians were aware that CT scans may be associated with an increased risk of cancer, they write.

Addressing the Knowledge Gap

One potential explanation for this knowledge gap, they add, is the lack of adequate integration of the topic in medical school and postgraduate training curricula. The statement suggests that medical school, along with residency and fellowship training, present crucial opportunities to communicate knowledge about ionizing radiation that should be reinforced during postgraduate training. Additionally, it advises that training should be done in “tracks” tailored to the differing needs of clinicians who request imaging and those who actually perform it.

Specifically, clinicians who perform cardiac imaging—including interventional cardiologists and electrophysiologistsshould be required to demonstrate adequate knowledge of contemporary dose-optimization techniques for patients and dose-minimization techniques for operators and staff. They should also be well versed in routine use of appropriate use criteria (AUC).

Training in this area also should “develop the trainee’s ability to communicate these complex scientific issues in a manner that patients can understand,” the statement recommends.

But developing the necessary curricula, Dr. Fazel and colleagues say, will require collaboration between “relevant stakeholders” including the American College of Cardiology Foundation, the American Board of Internal Medicine, the American Board of Radiology, and the American Council for Graduate Medical Education. The writing committee also recommends requiring that clinicians who perform imaging studies with ionizing radiation attend training sessions, either at national scientific meetings or at the institutional level, and receive credentialing in radiation safety procedures.

While emphasizing shared decision making, the writing committee also acknowledges that meaningful, effective communication with patients can be challenging given the technical nature of the radiation conversation. To make things easier, they recommend:

  • Using simple language that highlights the benefits of an accurate diagnosis and the importance of early detection and therapeutic intervention
  • Affirming that the imaging study is appropriate (or uncertain/may be appropriate) based on the AUC or appropriate use of imaging criteria
  • Allowing the patient to ask questions
  • Directly addressing patient and family concerns regarding risks of ionizing radiation, contrast media, and anesthesia
  • Comparing radiation exposure risks to commonly performed tasks, such as driving a car

Better Patient Awareness, Follow-up Needed

The document also touches on the issue of informed consent in the context of shared decision making. For nonemergent, fluoroscopically-guided cardiac procedures such as PCI, structural heart interventions, and electrophysiology procedures, “discussion of the potential for exceeding the thresholds for deterministic effects of radiation exposure,” including hair loss and skin injury, should be part of the process. Dr. Fazel and colleagues recommend that patients be offered postprocedure education about radiation exposure before discharge and alongside follow-up.

Data on radiation exposure need to be publicly available, the statement argues. Currently, exposure resulting from specific cardiac imaging procedures is not routinely recorded or archived, Dr. Fazel and colleagues note, although most imaging devices record this information. They recommend that all cardiac imaging facilities keep “all relevant radiation-related data in an appropriate database [to be] archived and audited regularly for quality assurance and benchmarking.” Additionally, they call for routine, mandated collection of available radiation data from clinical studies, which could be useful for developing diagnostic reference levels for specific patient populations.

“Finally, the continually expanding repertoire of techniques that allow for high-quality imaging with lower radiation exposure should be used when available,” Dr. Fazel and colleagues write. “The implementation of these strategies in practice is necessary to achieve high-quality, patient-centered imaging and will require a shared effort and investment by all stakeholders, including physicians, patients, national scientific and educational organizations, politicians, and industry.”


Fazel R, Gerber TC, Balter B, et al. Approaches to enhancing radiation safety in cardiovascular imaging: a scientific statement from the American Heart Association. Circulation. 2014;Epub ahead of print.




  • Dr. Fazel reports no relevant conflicts of interest.

Related Stories:


We Recommend