RESUMO
The stimulus to create this document was the recognition that ionizing radiation-guided cardiovascular procedures are being performed with increasing frequency, leading to greater patient radiation exposure and, potentially, to greater exposure to clinical personnel. While the clinical benefit of these procedures is substantial, there is concern about the implications of medical radiation exposure. ACC leadership concluded that it is important to provide practitioners with an educational resource that assembles and interprets the current radiation knowledge base relevant to cardiovascular procedures. By applying this knowledge base, cardiovascular practitioners will be able to select procedures optimally, and minimize radiation exposure to patients and to clinical personnel. "Optimal Use of Ionizing Radiation in Cardiovascular Imaging - Best Practices for Safety and Effectiveness" is a comprehensive overview of ionizing radiation use in cardiovascular procedures and is published online. To provide the most value to our members, we divided the print version of this document into 2 focused parts. "Part I: Radiation Physics and Radiation Biology" addresses radiation physics, dosimetry and detrimental biologic effects. "Part II: Radiologic Equipment Operation, Dose-Sparing Methodologies, Patient and Medical Personnel Protection" covers the basics of operation and radiation delivery for the 3 cardiovascular imaging modalities (x-ray fluoroscopy, x-ray computed tomography, and nuclear scintigraphy). For each modality, it includes the determinants of radiation exposure and techniques to minimize exposure to both patients and to medical personnel.
Assuntos
Técnicas de Imagem Cardíaca/normas , Doenças Cardiovasculares/diagnóstico por imagem , Exposição Ocupacional/normas , Doses de Radiação , Exposição à Radiação/normas , Benchmarking/normas , Consenso , Medicina Baseada em Evidências/normas , Humanos , Exposição Ocupacional/efeitos adversos , Exposição Ocupacional/prevenção & controle , Segurança do Paciente/normas , Valor Preditivo dos Testes , Exposição à Radiação/efeitos adversos , Exposição à Radiação/prevenção & controle , Medição de Risco , Fatores de RiscoRESUMO
The stimulus to create this document was the recognition that ionizing radiation-guided cardiovascular procedures are being performed with increasing frequency, leading to greater patient radiation exposure and, potentially, to greater exposure for clinical personnel. Although the clinical benefit of these procedures is substantial, there is concern about the implications of medical radiation exposure. The American College of Cardiology leadership concluded that it is important to provide practitioners with an educational resource that assembles and interprets the current radiation knowledge base relevant to cardiovascular procedures. By applying this knowledge base, cardiovascular practitioners will be able to select procedures optimally, and minimize radiation exposure to patients and to clinical personnel. Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness is a comprehensive overview of ionizing radiation use in cardiovascular procedures and is published online. To provide the most value to our members, we divided the print version of this document into 2 focused parts. Part I: Radiation Physics and Radiation Biology addresses the issue of medical radiation exposure, the basics of radiation physics and dosimetry, and the basics of radiation biology and radiation-induced adverse effects. Part II: Radiological Equipment Operation, Dose-Sparing Methodologies, Patient and Medical Personnel Protection covers the basics of operation and radiation delivery for the 3 cardiovascular imaging modalities (x-ray fluoroscopy, x-ray computed tomography, and nuclear scintigraphy) and will be published in the next issue of the Journal.
Assuntos
Técnicas de Imagem Cardíaca/normas , Doenças Cardiovasculares/diagnóstico por imagem , Doses de Radiação , Exposição à Radiação/normas , Benchmarking/normas , Consenso , Medicina Baseada em Evidências/normas , Humanos , Segurança do Paciente/normas , Valor Preditivo dos Testes , Exposição à Radiação/efeitos adversos , Exposição à Radiação/prevenção & controle , Medição de Risco , Fatores de RiscoAssuntos
Técnicas de Imagem Cardíaca/normas , Doenças Cardiovasculares/diagnóstico por imagem , Doses de Radiação , Exposição à Radiação/normas , Benchmarking/normas , Consenso , Medicina Baseada em Evidências/normas , Humanos , Segurança do Paciente/normas , Valor Preditivo dos Testes , Exposição à Radiação/efeitos adversos , Exposição à Radiação/prevenção & controle , Medição de Risco , Fatores de RiscoRESUMO
Education, justification, and optimization are the cornerstones to enhancing the radiation safety of medical imaging. 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. 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. Limiting the use of imaging to appropriate clinical indications can ensure that the benefits of imaging outweigh any potential risks. Finally, the continually expanding repertoire of techniques that allow high-quality imaging with lower radiation exposure should be used when available to achieve safer imaging. 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.
Assuntos
American Heart Association , Cardiologia/normas , Doenças Cardiovasculares/diagnóstico por imagem , Doses de Radiação , Lesões por Radiação/prevenção & controle , Cardiologia/educação , Educação Médica/normas , Humanos , Radiografia , Estados UnidosAssuntos
Técnicas de Diagnóstico Cardiovascular , Isquemia Miocárdica/diagnóstico , Algoritmos , Dor no Peito/etiologia , Estenose Coronária/diagnóstico , Estenose Coronária/fisiopatologia , Tomada de Decisões , Técnicas de Diagnóstico Cardiovascular/efeitos adversos , Medicina Baseada em Evidências , Teste de Esforço , Tolerância ao Exercício , Feminino , Humanos , Isquemia Miocárdica/fisiopatologia , Neoplasias Induzidas por Radiação/etiologia , Neoplasias Induzidas por Radiação/prevenção & controle , Doses de Radiação , Risco , Avaliação de SintomasRESUMO
The current paper details the recommendations arising from an NIH-NHLBI/NCI-sponsored symposium held in November 2012, aiming to identify key components of a radiation accountability framework fostering patient-centered imaging and shared decision-making in cardiac imaging. Symposium participants, working in 3 tracks, identified key components of a framework to target critical radiation safety issues for the patient, the laboratory, and the larger population of patients with known or suspected cardiovascular disease. The use of ionizing radiation during an imaging procedure should be disclosed to all patients by the ordering provider at the time of ordering, and reinforced by the performing provider team. An imaging protocol with effective dose ≤3 mSv is considered very low risk, not warranting extensive discussion or written informed consent. However, a protocol effective dose >20 mSv was proposed as a level requiring particular attention in terms of shared decision-making and either formal discussion or written informed consent. Laboratory reporting of radiation dosimetry is a critical component of creating a quality laboratory fostering a patient-centered environment with transparent procedural methodology. Efforts should be directed to avoiding testing involving radiation, in patients with inappropriate indications. Standardized reporting and diagnostic reference levels for computed tomography and nuclear cardiology are important for the goal of public reporting of laboratory radiation dose levels in conjunction with diagnostic performance. The development of cardiac imaging technologies revolutionized cardiology practice by allowing routine, noninvasive assessment of myocardial perfusion and anatomy. It is now incumbent upon the imaging community to create an accountability framework to safely drive appropriate imaging utilization.
Assuntos
Cardiologia/métodos , Doenças Cardiovasculares/diagnóstico , Tomada de Decisões , Diagnóstico por Imagem/métodos , Assistência Centrada no Paciente/métodos , Lesões por Radiação/prevenção & controle , Humanos , Doses de Radiação , Radiação IonizanteRESUMO
OBJECTIVE: The purpose of this article is to discuss whether and how the risks of exposure to ionizing radiation should affect clinical decision making in patients with known or suspected cardiovascular disease. CONCLUSION: Although the prevalence of cardiovascular disease and frequency of diagnostic testing has risen dramatically, cardiovascular mortality has declined. Earlier and more accurate detection of cardiovascular disease may play an important role. Concerns regarding excessive radiation exposure from cardiovascular imaging have been raised. Efforts to reduce exposure have included selection of appropriate patients for cardiovascular testing, technologic advances, educational resources, and a directed patient-centered approach to testing.
Assuntos
Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/mortalidade , Tomada de Decisões , Doses de Radiação , Lesões por Radiação/epidemiologia , Tomografia Computadorizada por Raios X/mortalidade , Doenças Cardiovasculares/prevenção & controle , Comorbidade , Humanos , Prevalência , Medição de RiscoAssuntos
Gerenciamento Clínico , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/terapia , Síndrome Coronariana Aguda/epidemiologia , Antagonistas Adrenérgicos beta/administração & dosagem , Consumo de Bebidas Alcoólicas , Angina Pectoris/tratamento farmacológico , Peso Corporal , LDL-Colesterol/sangue , Clopidogrel , Comorbidade , Efeitos Psicossociais da Doença , Depressão/tratamento farmacológico , Depressão/epidemiologia , Complicações do Diabetes/diagnóstico , Complicações do Diabetes/terapia , Eletrocardiografia , Exercício Físico/fisiologia , Teste de Esforço , Hemoglobinas Glicadas/análise , Comportamentos Relacionados com a Saúde , Humanos , Hipertensão/prevenção & controle , Estilo de Vida , Infarto do Miocárdio/prevenção & controle , Isquemia Miocárdica/tratamento farmacológico , Isquemia Miocárdica/economia , Isquemia Miocárdica/epidemiologia , Revascularização Miocárdica , Exame Físico , Inibidores da Agregação Plaquetária/administração & dosagem , Inibidores da Agregação Plaquetária/uso terapêutico , Guias de Prática Clínica como Assunto , Qualidade de Vida , Medição de Risco , Fatores de Risco , Comportamento de Redução do Risco , Abandono do Hábito de Fumar , Ticlopidina/administração & dosagem , Ticlopidina/análogos & derivados , Ticlopidina/uso terapêuticoRESUMO
Informed consent ideally results in patient autonomy and rational health care decisions. Frequently, patients face complex medical decisions that require a delicate balancing of anticipated benefits and potential risks, which is the concept of informed consent. This balancing process requires an understanding of available medical evidence and alternative medical options, and input from experienced physicians. The informed consent doctrine places a positive obligation on physicians to partner with patients as they try to make the best decision for their specific medical situation. The high prevalence and mortality related to heart disease in our society has led to increased cardiac imaging with modalities that use ionizing radiation. This paper reviews how physicians can meet the ideals of informed consent when considering cardiac imaging with ionizing radiation, given the limited evidence for risks and benefits. The goal is an informed patient making rational choices based on available medical information.
Assuntos
Diagnóstico por Imagem , Cardiopatias/diagnóstico , Consentimento Livre e Esclarecido , Doses de Radiação , Angiografia Coronária , Diagnóstico por Imagem/efeitos adversos , Diagnóstico por Imagem/ética , Diagnóstico por Imagem/métodos , Medicina Baseada em Evidências , Cardiopatias/diagnóstico por imagem , Cardiopatias/mortalidade , Humanos , Consentimento Livre e Esclarecido/ética , Consentimento Livre e Esclarecido/legislação & jurisprudência , Responsabilidade Legal , Imagem de Perfusão , Relações Médico-Paciente , Valor Preditivo dos Testes , Prognóstico , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Tomografia Computadorizada de Emissão , Tomografia Computadorizada por Raios X , Revelação da VerdadeRESUMO
Technological advances and increased utilization of medical testing and procedures have prompted greater attention to ensuring the patient safety of radiation use in the practice of adult cardiovascular medicine. In response, representatives from cardiovascular imaging societies, private payers, government and nongovernmental agencies, industry, medical physicists, and patient representatives met to develop goals and strategies toward this end; this report provides an overview of the discussions. This expert "think tank" reached consensus on several broad directions including: the need for broad collaboration across a large number of diverse stakeholders; clarification of the relationship between medical radiation and stochastic events; required education of ordering and providing physicians, and creation of a culture of safety; development of infrastructure to support robust dose assessment and longitudinal tracking; continued close attention to patient selection by balancing the benefit of cardiovascular testing and procedures against carefully minimized radiation exposures; collation, dissemination, and implementation of best practices; and robust education, not only across the healthcare community but also to patients, the public, and media. Finally, because patient radiation safety in cardiovascular imaging is complex, any proposed actions need to be carefully vetted (and monitored) for possible unintended consequences.
RESUMO
Technological advances and increased utilization of medical testing and procedures have prompted greater attention to ensuring the patient safety of radiation use in the practice of adult cardiovascular medicine. In response, representatives from cardiovascular imaging societies, private payers, government and nongovernmental agencies, industry, medical physicists, and patient representatives met to develop goals and strategies toward this end; this report provides an overview of the discussions. This expert "think tank" reached consensus on several broad directions including: the need for broad collaboration across a large number of diverse stakeholders; clarification of the relationship between medical radiation and stochastic events; required education of ordering and providing physicians, and creation of a culture of safety; development of infrastructure to support robust dose assessment and longitudinal tracking; continued close attention to patient selection by balancing the benefit of cardiovascular testing and procedures against carefully minimized radiation exposures; collation, dissemination, and implementation of best practices; and robust education, not only across the healthcare community, but also to patients, the public, and media. Finally, because patient radiation safety in cardiovascular imaging is complex, any proposed actions need to be carefully vetted (and monitored) for possible unintended consequences.
Assuntos
Doenças Cardiovasculares/diagnóstico , Segurança do Paciente/normas , Proteção Radiológica/normas , Radiografia/normas , Cintilografia/normas , Adulto , Cardiologia/normas , Doenças Cardiovasculares/terapia , Educação , Humanos , Relações Interprofissionais , Cultura Organizacional , Indicadores de Qualidade em Assistência à Saúde , Proteção Radiológica/métodos , Radiometria , Estados UnidosRESUMO
Technological advances and increased utilization of medical testing and procedures have prompted greater attention to ensuring the patient safety of radiation use in the practice of adult cardiovascular medicine. In response, representatives from cardiovascular imaging societies, private payers, government and nongovernmental agencies, industry, medical physicists, and patient representatives met to develop goals and strategies toward this end; this report provides an overview of the discussions. This expert "think tank" reached consensus on several broad directions including: the need for broad collaboration across a large number of diverse stakeholders; clarification of the relationship between medical radiation and stochastic events; required education of ordering and providing physicians, and creation of a culture of safety; development of infrastructure to support robust dose assessment and longitudinal tracking; continued close attention to patient selection by balancing the benefit of cardiovascular testing and procedures against carefully minimized radiation exposures; collation, dissemination, and implementation of best practices; and robust education, not only across the healthcare community, but also to patients, the public, and media. Finally, because patient radiation safety in cardiovascular imaging is complex, any proposed actions need to be carefully vetted (and monitored) for possible unintended consequences.