Drivers of radiation dose reduction with myocardial perfusion imaging: A large health system experience
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Despite increasing emphasis on reducing radiation exposure from myocardial perfusion imaging (MPI), the use of radiation-sparing practices (RSP) at nuclear laboratories remains limited. Defining real-world impact of RSPs on effective radiation dose (E) can potentially further motivate their adoption.
MPI studies performed between 1/2010 and 12/2016 within a single health system were included. Mean E was compared between sites with ‘basic’ RSP (defined as elimination of thallium-based protocols and use of stress-only (SO) imaging on conventional single photon emission computed tomography (SPECT) cameras) and those with ‘advanced’ capabilities (sites that additionally used solid-state detector (SSD) SPECT cameras, advanced post-processing software (APPS) or positron emission tomography (PET) imaging), after matching patients by age, gender, and weight. Contributions of individual RSP to E reduction were determined using multiple linear regression after adjusting for factors affecting tracer dose.
Among 55,930 MPI studies performed, the use of advanced RSP was associated with significantly lower mean E compared to basic RSP (7 ± 5.6 mSv and 16 ± 5.4 mSv, respectively; P < 0.001), with a greater likelihood of achieving E < 9 mSv (65.7% vs. 10.8%, respectively; OR 15.8 [95% CI 14 to 17.8]; P < 0.0001). Main driver of E reduction was SO-SSD SPECT (mean reduction = 11.5 mSv), followed by use of SO-SPECT + APPS (mean reduction = 10.1 mSv), ;ET (mean reduction = 9.7 mSv); and elimination of thallium protocols (mean reduction = 9.1 mSv); P < 0.0001 for all comparisons.
In a natural experiment with implementation of radiation-saving practices at a large health system, stress-only protocols used in conjunction with modern SPECT technologies, the use of PET and elimination of thallium-based protocols were associated with greatest reductions in radiation dose. Availability of several approaches to dose reduction within a health system can facilitate achievement of targeted radiation benchmarks in a greater number of performed studies.
KeywordsMyocardial perfusion imaging radiation exposure effective dose
Coronary artery disease
Myocardial perfusion imaging
Positron emission tomography
Single photon emission computed tomography
Drs. Patel and Al Badarin are supported by the National Heart, Lung, And Blood Institute of the National Institutes of Health under Award Number T32HL110837. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dr. Spertus receives research grant support from Abbott Vascular, Novartis, and is the PI of an analytic center for the American College of Cardiology. He serves as a consultant to the United Healthcare, Bayer, Janssen, AstraZeneca, and Novartis. He has an equity interest in the Health Outcomes Sciences. Dr. Bateman receives research grant support from Astellas and GE Healthcare. He serves as a consultant to GE Healthcare. He has ownership interest in Cardiovascular Imaging Technologies. He has intellectual property rights for Imagen Pro/MD/Q/3D software. The other authors have no conflicts of interest to disclose.
- 6.Einstein AJ, Berman DS, Min JK, Hendel RC, Gerber TC, Carr JJ, Cerqueira MD, Cullom SJ, DeKemp R, Dickert NW, Dorbala S, Fazel R, Garcia EV, Gibbons RJ, Halliburton SS, Hausleiter J, Heller GV, Jerome S, Lesser JR, Raff GL, Tilkemeier P, Williams KA, Shaw LJ. Patient-centered imaging: shared decision making for cardiac imaging procedures with exposure to ionizing radiation. J Am Coll Cardiol 2014;63:1480-9.CrossRefGoogle Scholar
- 13.Einstein AJ, Pascual TN, Mercuri M, Karthikeyan G, Vitola JV, Mahmarian JJ, Better N, Bouyoucef SE, Hee-Seung Bom H, Lele V, Magboo VP, Alexanderson E, Allam AH, Al-Mallah MH, Flotats A, Jerome S, Kaufmann PA, Luxenburg O, Shaw LJ, Underwood SR, Rehani MM, Kashyap R, Paez D, Dondi M, Group II. Current worldwide nuclear cardiology practices and radiation exposure: results from the 65 country IAEA Nuclear Cardiology Protocols Cross-Sectional Study (INCAPS). Eur Heart J 2015;36:1689-96.CrossRefGoogle Scholar
- 15.Lindner O, Pascual TN, Mercuri M, Acampa W, Burchert W, Flotats A, Kaufmann PA, Kitsiou A, Knuuti J, Underwood SR, Vitola JV, Mahmarian JJ, Karthikeyan G, Better N, Rehani MM, Kashyap R, Dondi M, Paez D, Einstein AJ. Nuclear cardiology practice and associated radiation doses in Europe: results of the IAEA Nuclear Cardiology Protocols Study (INCAPS) for the 27 European countries. Eur J Nucl Med Mol Imaging 2016;43:718-28.CrossRefGoogle Scholar
- 17.Mercuri M, Pascual TN, Mahmarian JJ, Shaw LJ, Rehani MM, Paez D, Einstein AJ, Group II. Comparison of radiation doses and best-practice use for myocardial perfusion imaging in US and non-US laboratories: Findings from the IAEA (International Atomic Energy Agency) Nuclear Cardiology Protocols Study. JAMA Intern Med 2016;176:266-9.CrossRefGoogle Scholar
- 21.Venero CV, Heller GV, Bateman TM, McGhie AI, Ahlberg AW, Katten D, Courter SA, Golub RJ, Case JA, Cullom SJ. A multicenter evaluation of a new post-processing method with depth-dependent collimator resolution applied to full-time and half-time acquisitions without and with simultaneously acquired attenuation correction. J Nucl Cardiol 2009;16:714-25.CrossRefGoogle Scholar
- 23.1990 Recommendations of the International Commission on Radiological Protection. Ann ICRP 1991;21:1-201.Google Scholar
- 24.Conversion coefficients for use in radiological protection against external radiation. Adopted by the ICRP and ICRU in September 1995. Ann ICRP 1996;26:1-205.Google Scholar
- 27.https://www.fda.gov/radiation-emittingproducts/radiationemittingproductsandprocedures/medicalimaging/medicalx-rays/ucm115329.htm. US Food and Drug Administration. What are the radiation risks from CT?.