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ICRP: Free the Annals!

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Submitted by David R. Holmes, Jr., American College of Cardiology
   Commenting on behalf of the organisation
Document Patient and Staff Radiological Protection in Cardiology

August 18, 2011

The American College of Cardiology (ACC) appreciates the opportunity to provide the International Commission on Radiation Protection (ICRP) with comments on its draft report Patient and Staff Radiological Protection in Cardiology. The ACC is transforming cardiovascular care and improving heart health through continuous quality improvement, patient-centered care, payment innovation and professionalism. The College is a 40,000 member nonprofit medical society comprised of physicians, nurses, nurse practitioners, physician assistants, pharmacists and practice managers, and bestows credentials upon cardiovascular specialists who meet its stringent qualifications. The College is a leader in the formulation of health policy, standards and guidelines, and is a staunch supporter of cardiovascular research. The ACC provides professional education and operates national registries for the measurement and improvement of quality care.



In recent years, technology has had a significant effect on the practice of cardiovascular medicine. The rise in the availability of diagnostic imaging tools has provided cardiovascular professionals with new ability to diagnose and treat cardiovascular diseases. Along with that rise in availability has come an increasing awareness of the potential detrimental effects of radiation and the need to ensure radiation protection for both patients undergoing the test and the medical professionals performing it. The draft report contains a comprehensive, cogent summary of the effects of radiation exposure, as well techniques in managing this exposure in different cardiovascular procedure and testing situations, and the ACC commends the ICRP for its fair and balanced review of these issues, as well as the critical recommendations for patient and staff protection from radiation exposure. The report not only discusses methods for protecting both patients and cardiovascular professionals, but it also provides detailed summaries for optimizing radiation exposure to the patient, as well as staff. Both of these will be useful for cardiovascular professionals providing diagnostic imaging services.


The ACC strives to promote the importance of using these tools appropriately as one way of minimizing radiation exposure for patients. The College recognizes that diagnostic imaging tests carries some risk, but the risk must be considered along with the demonstrable benefits. These diagnostic imaging procedures and tests have led to a significant decrease in the mortality of cardiovascular disease. Because of these clear benefits for patients with cardiovascular disease, the ACC believes it is critical that cardiovascular professionals focus on providing the appropriate test for the appropriate patient at the appropriate time as a method of reducing the risks associated with radiation exposure.


As such, the ACC has developed Appropriate Use Criteria (AUC) for various cardiac imaging tools and made them available to the public at Additionally, the ACC has developed and made available to its members FOCUS, a national quality improvement initiative designed to help cardiovascular professionals best use AUC and ultimately reduce inappropriate imaging. FOCUS participants communicate through a web-based community to develop best practices for implementing AUC for computed tomography, stress and resting echo and radionuclide imaging. The program resources below are free and include open access to an e-mail listserv to exchange ideas; interactive Webinars; tools to help measure and document improvement; and resources and applications to optimize AUC use. Use of these programs will protect not only patients from excess radiation. By ensuring patients undergo imaging tests when appropriate, radiation exposure of cardiovascular professionals is also reduced. The ACC is pleased to note the ICRP’s recognition of the importance of AUC and the beneficial effects they can have on reducing exposure to inappropriate.


In addition to ensuring that the appropriate tests are given to the right patient at the appropriate time, the ACC believes it is critical that cardiovascular professionals who perform diagnostic imaging services are properly educated. Specialty societies provide the appropriate forum for such education. As such, the ACC offers a wide variety of educational offerings on diagnostic imaging in various formats. Additionally, the ACC’s Core Cardiovascular Training Symposiums, commonly known as COCATS, and expert consensus documents address training on radiation protection, symptoms of radiation exposure, and the amount of experience cardiologists need to be considered proficient in cardiac imaging modalities. These efforts help to ensure cardiovascular professionals are appropriately trained to perform diagnostic imaging services, minimizing radiation exposure for both patients and medical staff. The ACC would welcome the opportunity to work with the ICRP to promote cardiovascular professional education and training on diagnostic imaging and measures to promote radiation safety.


The ICRP’s recommendations place some onus on healthcare providers to track and audit patient radiation doses. This emphasis on monitoring is appropriate when it is considered in the context of the need for increasing the amount of attention paid to radiation doses during cardiac procedures. Additionally, it also appropriately highlights the need for better education for cardiovascular professionals on this subject. However, it is equally critical to recognize that the lack of consensus in dose measurement between testing modalities makes it difficult to determine total exposure for both patients and medical staff. The ACC recommends that the ICRP expand on the discussion of this issue in its report.


Additionally, the ICRP includes among its recommendations the need for informed consent regarding the potential radiation-related risks. The College believes that all healthcare should be patient centered. As such, it is critical that patients understand both the benefits and risks of what it is they consent to when they decide, working with their physician, that it is appropriate to undergo a test or procedure. There are benefits to the medical uses of radioactive materials, but there are, as with most tests and procedures, risks, as well. The informed consent process is designed to educate patients about both the benefits and the risks, and radiation risks should be included as part of that process. The ACC strongly supports this recommendation.


The ACC agrees that patient dose reports should be produced at the end of procedures and that these reports should be incorporated into patient medical records. The College urges the ICRP to include recommendations regarding the content of those reports, such as which dose parameters should be recorded, so as to promote standardization. In a similar vein, the ACC believes the ICRP should encourage manufacturers to develop systems that report these standard parameters, which would allow for comparisons across systems.


The ACC appreciates the opportunity to provide input to the ICRP and welcomes the opportunity to work together on such important issues as these. If there are any questions regarding these comments, please contact Lisa P. Goldstein, Regulatory Affairs Associate Director at (202) 375-6527 or via e-mail at

David R. Holmes, Jr., M.D., F.A.C.C.