The ACC has joined the Society for Cardiovascular Angiography & Interventions (SCAI) and seven other medical societies in calling for fluoroscopy laboratories to implement an enhanced safety framework: ALARA+ or "As Low and As Light as Reasonably Achievable."

A report detailing the framework, simultaneously published today in JSCAI, Heart Rhythm, the Journal of Vascular and Interventional Radiology and the Journal of Vascular Surgery-Vascular Insights, dives into the health, financial and workforce impact of fluoroscopy-guided settings; addresses the dual risks of radiation exposure and orthopedic strain from traditional protective equipment; and lays out action steps for implementation.

"How we think about radiation safety has been historically guided by the ALARA principle, or 'as low as reasonably achievable.' But that approach has proven to be not safe enough for health care staff working in fluoroscopic labs," said Robert F. Riley, MD, MS, chair of the 2025 Summit on Radiation and Orthopedic Risks in Fluoroscopic Labs. "Traditional ALARA principles focused on incomplete methods of minimizing radiation exposure. Additionally, they did not fully account for the orthopedic strain caused by wearing heavy lead protective equipment during long procedures. The new framework, ALARA+, calls for responsible protection strategies that are 'as low and as light as reasonably achievable' for the entire team."

In their report, Arash Salavitabar, MD, FACC, et al., present the following recommendations to improve lab safety: 1) accelerating the adoption of modern radiation protection technologies, such as suspended, freestanding or table-mounted shielding systems; 2) expanding real-time radiation monitoring, enabling clinicians to reduce exposure during procedures via immediate feedback; 3) strengthening education and training in radiation safety; 4) continuing technological innovation to protect all catheterization lab clinicians; and 5) supporting regulatory and accreditation standards that promote safer fluoroscopy laboratory environments.

The authors acknowledge two main barriers to enhanced radiation protection device (ERPD) adoption: "determining which clinical applications are well-suited to the commercially available ERPDs" and "operator education and acceptance of ERPD." However, they note that "for many operators, ERPDs clearly represent an opportunity to reduce their personal exposure" and "nearly eliminate the potential orthopedic injuries of personal radiation protection."

Moving forward, the authors call for institutional support "to fund and prioritize these measures to maintain the health and well-being of their clinicians," manufacturers innovating ergonomic solutions, legislative advocacy to reimburse institutional costs of ERPD implementation, and the development of multisocietal guidelines to establish consistent radiation and ergonomic standards across subspecialties working in the fluoroscopic lab.

Clinical Topics: Cardiovascular Care Team, Noninvasive Imaging, Nuclear Imaging

Keywords: Radiology, Interventional, Catheterization, Fluoroscopy, ACC Advocacy, Workforce, Radiation Protection