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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)

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Journal of Nuclear Cardiology Aims and scope

Abstract

Background

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.

Conclusions

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.

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Abbreviations

ALARA:

As low as reasonably achievable

ED:

Effective dose

IAEA:

International Atomic Energy Agency

IHD:

Ischemic heart disease

INCAPS:

IAEA nuclear cardiology protocols study

IQR:

Interquartile range

LA:

Latin America

MPI:

Myocardial perfusion imaging

NC:

Nuclear cardiology

QI:

Quality index

RoW:

Rest of world

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Funding

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

Disclosures

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

Author information

Authors and Affiliations

  1. Quanta Diagnóstico & Terapia, Curitiba, Brazil

    João V. Vitola MD, PhD

  2. Departamento de Medicina Nuclear, Asociación Española, Montevideo, Uruguay

    Fernando Mut MD

  3. Departamento de Cardiología Nuclear, Instituto Nacional de Cardiología “Ignacio Chávez”, Mexico, Mexico

    Erick Alexánderson MD

  4. Section of Nuclear Medicine and Diagnostic Imaging, Division of Human Health, International Atomic Energy Agency, Vienna, Austria

    Thomas N. B. Pascual MD, MHPEd, Ravi Kashyap MD, Maurizio Dondi MD & Diana Paez MD

  5. Division of Cardiology, Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital, 622 West 168th Street PH 10-203, New York, NY, 10032, USA

    Mathew Mercuri PhD & Andrew J. Einstein MD, PhD

  6. Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India

    Ganesan Karthikeyan MD, DM, MSc

  7. Department of Nuclear Medicine, Royal Melbourne Hospital and University of Melbourne, Parkville, Australia

    Nathan Better MBBS, FRACP

  8. Radiation Protection of Patients Unit, International Atomic Energy Agency, Vienna, Austria

    Madan M. Rehani PhD

  9. Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA

    Madan M. Rehani PhD

  10. Department of Radiology, Columbia University Medical Center and New York-Presbyterian Hospital, New York, NY, USA

    Andrew J. Einstein MD, PhD

Authors
  1. João V. Vitola MD, PhD
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  2. Fernando Mut MD
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  3. Erick Alexánderson MD
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  4. Thomas N. B. Pascual MD, MHPEd
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  5. Mathew Mercuri PhD
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  6. Ganesan Karthikeyan MD, DM, MSc
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  7. Nathan Better MBBS, FRACP
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  8. Madan M. Rehani PhD
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  9. Ravi Kashyap MD
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  10. Maurizio Dondi MD
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  11. Diana Paez MD
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  12. Andrew J. Einstein MD, PhD
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Consortia

The INCAPS Investigators Group

Corresponding author

Correspondence to Andrew J. Einstein MD, PhD.

Additional information

On behalf of Members of the INCAPS Investigators Group.

The members of INCAPS Investigators Group are given in Appendix.

See related editorial, doi: 10.1007/s12350-016-0454-y.

Appendix

Appendix

Executive Committee: A.J. Einstein (chair), T.N.B. Pascual (IAEA project lead), D. Paez (IAEA section head), M. Dondi (IAEA section head); (alphabetically) N. Better, S.E. Bouyoucef, G. Karthikeyan, R. Kashyap, V. Lele, V.P.C. Magboo, F. Mut, J.J. Mahmarian, J.B. Meeks, M. Mercuri, M.M. Rehani, J.V. Vitola.

Regional Coordinators (alphabetically): E. Alexánderson (Latin America), A. Allam (Africa/Middle East), M.H. Al-Mallah (Middle East), N. Better (Oceania), S.E. Bouyoucef (Africa), H. Bom (East Asia), A. Flotats (Europe), S. Jerome (United States), P.A. Kaufmann (Europe), V. Lele (South Asia), O. Luxenburg (Israel), J. Mahmarian (North America), L.J. Shaw (North America), S.R. Underwood (United Kingdom), J. Vitola (Latin America).

Members (alphabetical order, by region): Africa: W. Amouri, H. Essabbah, S.S. Gassama, K.B. Makhdomi, G.I.E. El Mustapha, N. El Ouchdi, N. Qaïs, N. Soni, W. Vangu. Asia: R.M. Abazid, B. Adams, V. Agarwal, M.A. Alfeeli, N. Alnafisi, L. Bernabe, G.G. Bural, T. Chaiwatanarat, J.M. Chandraguptha, G.J. Cheon, I. Cho, A.S. Dogan, M. Eftekhari, A. Frenkel, I. Garty, S. George, P. Geramifar, H. Golan, S. Habib, R. Hussain, H. Im, H-J. Jeon, T. Kalawat, W.J. Kang, F. Keng, A. Klaipetch, P.G. Kumar, J. Lee, W.W. Lee, I. Lim, C.M.M. Macaisa, G. Malhotra, B.R. Mittal, M.H. Mohammad, P. Mohan, I.D. Mulyanto, D. Nariman, U.N. Nayak, K. Niaz, G. Nikolov, J.M. Obaldo, E. Ozturk, J.M. Park, S. Park, C.D. Patel, H.K. Phuong, A.P. Quinon, T.R. Rajini, Y. Saengsuda, J. Santiago, H.B. Sayman, A.S. Shinto, V. Sivasubramaniyan, M.H. Son, P. Sudhakar, G.M.S. Syed, N. Tamaki, K. Thamnirat, T. Thientunyakit, S. Thongmak, D.N. Velasco, A. Verma, U. Vutrapongwatana, Y. Wang, K.S. Won, Z. Yao, T. Yingsa-nga, R. Yudistiro, K.T. Yue, N. Zafrir. Europe: S.C. Adrian, D. Agostini, S. Aguadé, G. Armitage, M. Backlund, M. Backman, M. Baker, M.T. Balducci, C. Bavelaar, M. Berovic, F. Bertagna, R. Beuchel, A. Biggi, G. Bisi, R. Bonini, A. Bradley, L. Brudin, I. Bruno, E. Busnardo, R. Casoni, A. Choudhri, C. Cittanti, R. Clauss, D.C. Costa, M. Costa, K. Dixon, M. Dziuk, N. Egelic, I. Eriksson, G. Fagioli, D.B. de Faria, L. Florimonte, A. Francini, M. French, E. Gallagher, I. Garai, O. Geatti, D. Genovesi, L. Gianolli, A. Gimelli, E. del Giudice, S. Halliwell, M.J. Hansson, C. Harrison, F. Homans, F. Horton, D. Jędrzejuk, J. Jogi, A. Johansen, H. Johansson, M. Kalnina, M. Kaminek, A. Kiss, M. Kobylecka, M. Kostkiewicz, J. Kropp, R. Kullenberg, T. Lahoutte, O. Lang, Y.H. Larsson, M. Lázár, L. Leccisotti, N. Leners, O. Lindner, R.W. Lipp, A. Maenhout, L. Maffioli, C. Marcassa, B. Martins, P. Marzullo, G. Medolago, C.G. Mendiguchía, S. Mirzaei, M. Mori, B. Nardi, S. Nazarenko, K. Nikoletic, R. Oleksa, T. Parviainen, J. Patrina, R. Peace, C. Pirich, H. Piwowarska-Bilska, S. Popa, V. Prakash, V. Pubul, L. Puklavec, S. Rac, M. Ratniece, S.A. Rogan, A. Romeo, M. Rossi, D. Ruiz, N. Sabharwal, B.G. Salobir, A.I. Santos, S. Saranovic, A. Sarkozi, R.P. Schneider, R. Sciagra, S. Scotti, Z. Servini, L.R. Setti, S-Å. Starck, D. Vajauskas, J. Veselý, A. Vieni, A. Vignati, I.M. Vito, K. Weiss, D. Wild, M. Zdraveska-Kochovska. Latin America: R.N. Agüro, N. Alvarado, C.M. Barral, M. Beretta, I. Berrocal, J.F. Batista Cuellar, T-M. Cabral Chang, L.O. Cabrera Rodríguez, J. Canessa, G. Castro Mora, A.C. Claudia, G.F. Clavelo, A.F. Cruz Júnior, F.F. Faccio, K.M. Fernández, J.R. Gomez Garibo, U. Gonzalez, P. González E., M.A. Guzzo, J. Jofre, M. Kapitán, G. Kempfer, J.L. Lopez, T. Massardo V., I. Medeiros Colaco, C.T. Mesquita, M. Montecinos, S. Neubauer, L.M. Pabon, A. Puente, L.M. Rochela Vazquez, J.A. Serna Macias, A.G. Silva Pino, F.Z. Tártari Huber, A.P. Tovar, L. Vargas, C. Wiefels. North America: A. Aljizeeri, R.J. Alvarez, D. Barger, W. Beardwood, J. Behrens, L. Brann, D. Brown, H. Carr, K. Churchwell, G.A. Comingore, J. Corbett, M. Costello, F. Cruz, T. Depinet, S. Dorbala, M. Earles, F.P. Esteves, E. Etherton, R.J. Fanning, Jr., J. Fornace, L. Franks, H. Gewirtz, K. Gulanchyn, C-L. Hannah, J. Hays, J. Hendrickson, J. Hester, K. Holmes, S. Jerome, A. Johnson, C. Jopek, H. Lewin, J. Lyons, C. Manley, J. Meden, S. Moore, W.H. Moore, V. Murthy, R. Nace, D. Neely, L. Nelson, O. Niedermaier, D. Rice, R. Rigs, K. Schiffer, E. Schockling, T. Schultz, T. Schumacker, B. Sheesley, A. Sheikh, B. Siegel, A.M. Slim, J. Smith, M. Szulc, N. Tanskersley, P. Tilkemeier, G.D. Valdez, R. Vrooman, D. Wawrowicz, D.E. Winchester. Oceania: A. Alcheikh, B. Allen, E. Atkins, J. Bevan, C. Bonomini, J. Christiansen, L. Clack, E. Craig, H. Dixson, I. Duncan, S. Fredericks, S. Gales, R. Hampson, T. Hanley, K. Hartcher, J. Hassall, B. Kelley, S. Kelly, T. Kidd, T. de Kort, G. Larcos, W. Macdonald, C. McGrath, E. Murdoch, S. O’Malley, M. O’Rourke, M. Pack, R. Pearce, R. Praehofer, S. Ramsay, L. Scarlett, K. Smidt, F. Souvannavong, K. Taubman, G. Taylor, K. Tse, S. Unger, J. Weale.

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Vitola, J.V., Mut, F., Alexánderson, E. et al. 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). J. Nucl. Cardiol. 24, 851–859 (2017). https://doi.org/10.1007/s12350-016-0433-3

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