Approaches to Enhancing Radiation Safety in Cardiovascular Imaging: A Scientific Statement From the American Heart Association

Study Questions:

This American Heart Association Scientific Statement is endorsed by the American College of Cardiology as well as the relevant societies dealing with imaging techniques that utilize ionizing radiation. What are the problems and issues regarding patient safety and education, as well as recommendations for the future that are addressed in this statement?


The recommendations are based on extensive literature review as well as review of current recommendations and publicly available sources of information regarding radiation exposure in medical diseases. The majority of recommendations are at Level C and based predominately on consensus opinion of experts and standard of care.


The writing group identifies a number of problems in the clinical application of cardiovascular imaging, and the recommendations for current and future consideration include:

Problem 1: It is estimated that the rate of radiation exposure to the United States population for medical imaging increased sixfold between 1980 and 2014, at a time when per examination exposure remained constant or decreased. Approximately 40% of medical radiation exposure (outside of radiation therapy) is related to cardiovascular imaging and intervention.

Problem 2: Accurate determination of patient radiation dosing from imaging examinations is problematic. While the radiation energy delivered by the imaging device can be calculated, the actual amount of radiation absorption in a patient is dependent on multiple factors and less easily calculated.

Problem 3: There is a definite increased lifetime attributable risk for various forms of malignancy related to exposure to diagnostic radiographic procedures, which is greatest in female patients at a younger age and varies with the nature of radiation exposure.


Recommendations from the Study Group are as follows:

1. The key to enhancing radiation safety is education of patients and providers, ensuring appropriate justification that the imaging procedure is medically necessary, and optimization of imaging procedures to ensure radiation exposure is kept as low as reasonably achievable.

2. It is recommended that all health care providers requesting cardiac imaging credentials be required to know which cardiac tests use ionized radiation, the basic concepts related to medical radiation exposure including concepts of absorbed dose and effective dose, and typical estimated dose with commonly used procedures. All health care providers performing cardiac imaging with ionizing radiation should be required to demonstrate adequate knowledge of dose optimization techniques. Medical school, residency, and fellowship training should include specific training on radiation safety and effects of radiation. Referring physicians should be evaluated for their competency in referring for imaging using ionizing radiation and followed as part of maintenance of certification or board certification.

3. Nonemergent cardiac imaging using ionizing radiation should be performed on the basis of shared decision making with the patient, at which time the patient must be made aware of clinical justification and expected benefit, potential risk, and alternate forms of treatment.

4. If a patient’s radiation exposure related to a fluoroscopic procedure exceeds institutional triggers (not clearly defined), clinical follow-up for early detection and management of cutaneous injury should be arranged before discharge.

5. All facilities using cardiac imaging should record all relevant radiation-related data in an appropriate database, and exposure reports should be archived and audited regularly for quality assurance and benchmarking against future standards. Similar data should be required in clinical trials and reported as a part of clinical trial results.

Clinical Topics: Noninvasive Imaging

Keywords: Internship and Residency, Radiation, Health Personnel, Radiation, Ionizing, Standard of Care, Schools, Medical, Benchmarking, Diagnostic Imaging, Certification, Consensus

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