Journal of Nuclear Cardiology

, Volume 24, Issue 3, pp 851–859 | Cite as

Opportunities for improvement on current nuclear cardiology practices and radiation exposure in Latin America: Findings from the 65-country IAEA Nuclear Cardiology Protocols cross-sectional Study (INCAPS)

  • João V. Vitola
  • Fernando Mut
  • Erick Alexánderson
  • Thomas N. B. Pascual
  • Mathew Mercuri
  • Ganesan Karthikeyan
  • Nathan Better
  • Madan M. Rehani
  • Ravi Kashyap
  • Maurizio Dondi
  • Diana Paez
  • Andrew J. EinsteinEmail author
  • The INCAPS Investigators Group
Original Article



Comparison of Latin American (LA) nuclear cardiology (NC) practice with that in the rest of the world (RoW) will identify areas for improvement and lead to educational activities to reduce radiation exposure from NC.

Methods and Results

INCAPS collected data on all SPECT and PET procedures performed during a single week in March-April 2013 in 36 laboratories in 10 LA countries (n = 1139), and 272 laboratories in 55 countries in RoW (n = 6772). Eight “best practices” were identified a priori and a radiation-related Quality Index (QI) was devised indicating the number used. Mean radiation effective dose (ED) in LA was higher than in RoW (11.8 vs 9.1 mSv, p < 0.001). Within a populous country like Brazil, a wide variation in laboratory mean ED was found, ranging from 8.4 to 17.8 mSv. Only 11% of LA laboratories achieved median ED <9 mSv, compared to 32% in RoW (p < 0.001). QIs ranged from 2 in a laboratory in Mexico to 7 in a laboratory in Cuba. Three major opportunities to reduce ED for LA patients were identified: (1) more laboratories could implement stress-only imaging, (2) camera-based methods of ED reduction, including prone imaging, could be more frequently used, and (3) injected activity of 99mTc could be adjusted reflecting patient weight/habitus.


On average, radiation dose from NC is higher in LA compared to RoW, with median laboratory ED <9 mSv achieved only one third as frequently as in RoW. Opportunities to reduce radiation exposure in LA have been identified and guideline-based recommendations made to optimize protocols and adhere to the “as low as reasonably achievable” (ALARA) principle.


Nuclear cardiology SPECT PET Latin America best practices radiation dose 



As low as reasonably achievable


Effective dose


International Atomic Energy Agency


Ischemic heart disease


IAEA nuclear cardiology protocols study


Interquartile range


Latin America


Myocardial perfusion imaging


Nuclear cardiology


Quality index


Rest of world



Funding was obtained from the IAEA, the Margaret Q. Landenberger Research Foundation (in memory of Prof. A. Donny Strosberg), and the Irving Scholars Program.


Dr. Einstein has received research grants for other investigator-initiated studies from GE Healthcare, Philips Healthcare, Spectrum Dynamics, and Toshiba America Medical Systems.


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Copyright information

© American Society of Nuclear Cardiology 2016

Authors and Affiliations

  • João V. Vitola
    • 1
  • Fernando Mut
    • 2
  • Erick Alexánderson
    • 3
  • Thomas N. B. Pascual
    • 4
  • Mathew Mercuri
    • 5
  • Ganesan Karthikeyan
    • 6
  • Nathan Better
    • 7
  • Madan M. Rehani
    • 8
    • 9
  • Ravi Kashyap
    • 4
  • Maurizio Dondi
    • 4
  • Diana Paez
    • 4
  • Andrew J. Einstein
    • 5
    • 10
    Email author
  • The INCAPS Investigators Group
  1. 1.Quanta Diagnóstico & TerapiaCuritibaBrazil
  2. 2.Departamento de Medicina NuclearAsociación EspañolaMontevideoUruguay
  3. 3.Departamento de Cardiología NuclearInstituto Nacional de Cardiología “Ignacio Chávez”MexicoMexico
  4. 4.Section of Nuclear Medicine and Diagnostic Imaging, Division of Human HealthInternational Atomic Energy AgencyViennaAustria
  5. 5.Division of Cardiology, Department of MedicineColumbia University Medical Center and New York-Presbyterian HospitalNew YorkUSA
  6. 6.Department of CardiologyAll India Institute of Medical SciencesNew DelhiIndia
  7. 7.Department of Nuclear MedicineRoyal Melbourne Hospital and University of MelbourneParkvilleAustralia
  8. 8.Radiation Protection of Patients UnitInternational Atomic Energy AgencyViennaAustria
  9. 9.Harvard Medical SchoolMassachusetts General HospitalBostonUSA
  10. 10.Department of RadiologyColumbia University Medical Center and New York-Presbyterian HospitalNew YorkUSA

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