title: Nuclear cardiology practice and associated radiation doses in Europe: results of the IAEA Nuclear Cardiology Protocols Study (INCAPS) for the 27 European countries.
abstract: OBJECTIVE
  Nuclear cardiology is widely used to diagnose coronary artery disease and to guide patient management, but data on current practices, radiation dose-related best practices, and radiation doses are scarce. To address these issues, the IAEA conducted a worldwide study of nuclear cardiology practice. We present the European subanalysis.
  
  
  METHODS
  In March 2013, the IAEA invited laboratories across the world to document all SPECT and PET studies performed in one week. The data included age, gender, weight, radiopharmaceuticals, injected activities, camera type, positioning, hardware and software. Radiation effective dose was calculated for each patient. A quality score was defined for each laboratory as the number followed of eight predefined best practices with a bearing on radiation exposure (range of quality score 0 - 8). The participating European countries were assigned to regions (North, East, South, and West). Comparisons were performed between the four European regions and between Europe and the rest-of-the-world (RoW).
  
  
  RESULTS
  Data on 2,381 European patients undergoing nuclear cardiology procedures in 102 laboratories in 27 countries were collected. A cardiac SPECT study was performed in 97.9 % of the patients, and a PET study in 2.1 %. The average effective dose of SPECT was 8.0 ± 3.4 mSv (RoW 11.4 ± 4.3 mSv; P < 0.001) and of PET was 2.6 ± 1.5 mSv (RoW 3.8 ± 2.5 mSv; P < 0.001). The mean effective doses of SPECT and PET differed between European regions (P < 0.001 and P = 0.002, respectively). The mean quality score was 6.2 ± 1.2, which was higher than the RoW score (5.0 ± 1.1; P < 0.001). Adherence to best practices did not differ significantly among the European regions (range 6 to 6.4; P = 0.73). Of the best practices, stress-only imaging and weight-adjusted dosing were the least commonly used.
  
  
  CONCLUSIONS
  In Europe, the mean effective dose from nuclear cardiology is lower and the average quality score is higher than in the RoW. There is regional variation in effective dose in relation to the best practice quality score. A possible reason for the differences between Europe and the RoW could be the safety culture fostered by actions under the Euratom directives and the implementation of diagnostic reference levels. Stress-only imaging and weight-adjusted activity might be targets for optimization of European nuclear cardiology practice.
authors.affiliation: Institute of Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center North Rhine-Westphalia Bochum, University Hospital of the Ruhr University, Georgstr. 11, 32545, Bad Oeynhausen, Germany. olindner@hdz-nrw.de.
authors.forename: Oliver
authors.initials: O
authors.lastname: Lindner
authors.affiliation: Section of Nuclear Medicine and Diagnostic Imaging, Division of Human Health, International Atomic Energy Agency, Vienna, Austria.
authors.forename: Thomas N B
authors.initials: TN
authors.lastname: Pascual
authors.affiliation: Division of Cardiology, Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital, New York, NY, USA.
authors.forename: Mathew
authors.initials: M
authors.lastname: Mercuri
authors.affiliation: Institute of Biostructures and Bioimaging, National Council of Research, Naples, Italy.
authors.forename: Wanda
authors.initials: W
authors.lastname: Acampa
authors.affiliation: Institute of Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center North Rhine-Westphalia Bochum, University Hospital of the Ruhr University, Georgstr. 11, 32545, Bad Oeynhausen, Germany.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Burchert
authors.affiliation: Nuclear Medicine Department, Hospital de la Santa Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain.
authors.forename: Albert
authors.initials: A
authors.lastname: Flotats
authors.affiliation: Department of Nuclear Medicine and Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland.
authors.forename: Philipp A
authors.initials: PA
authors.lastname: Kaufmann
authors.affiliation: Department of Cardiology, Sismanoglio Hospital, Athens, Greece.
authors.forename: Anastasia
authors.initials: A
authors.lastname: Kitsiou
authors.affiliation: Turku PET Centre, University of Turku, and Turku University Hospital, Turku, Finland.
authors.forename: Juhani
authors.initials: J
authors.lastname: Knuuti
authors.affiliation: National Heart and Lung Institute, Imperial College London, London, UK.|Department of Nuclear Medicine, Royal Brompton and Harefield Hospitals, London, UK.
authors.forename: S Richard
authors.initials: SR
authors.lastname: Underwood
authors.affiliation: Quanta Diagnóstico & Terapia, Curitiba, Brazil.
authors.forename: João V
authors.initials: JV
authors.lastname: Vitola
authors.affiliation: Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, USA.
authors.forename: John J
authors.initials: JJ
authors.lastname: Mahmarian
authors.affiliation: Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Ganesan
authors.initials: G
authors.lastname: Karthikeyan
authors.affiliation: Department of Nuclear Medicine, Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia.
authors.forename: Nathan
authors.initials: N
authors.lastname: Better
authors.affiliation: Radiation Protection of Patients Unit, International Atomic Energy Agency, Vienna, Austria.|Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
authors.forename: Madan M
authors.initials: MM
authors.lastname: Rehani
authors.affiliation: Section of Nuclear Medicine and Diagnostic Imaging, Division of Human Health, International Atomic Energy Agency, Vienna, Austria.
authors.forename: Ravi
authors.initials: R
authors.lastname: Kashyap
authors.affiliation: Section of Nuclear Medicine and Diagnostic Imaging, Division of Human Health, International Atomic Energy Agency, Vienna, Austria.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Dondi
authors.affiliation: Section of Nuclear Medicine and Diagnostic Imaging, Division of Human Health, International Atomic Energy Agency, Vienna, Austria.
authors.forename: Diana
authors.initials: D
authors.lastname: Paez
authors.affiliation: Division of Cardiology, Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital, New York, NY, USA.|Department of Radiology, Columbia University Medical Center and New York-Presbyterian Hospital, New York, NY, USA.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Einstein
mesh_terms: D057791:Cardiac Imaging Techniques / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods* / Q000592:standards; D002309:Cardiology / Q000458:organization & administration; D005062:European Union; D009683:Nuclear Medicine / Q000458:organization & administration; D049268:Positron-Emission Tomography / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods* / Q000592:standards; D017410:Practice Guidelines as Topic; D011829:Radiation Dosage; D012958:Societies, Scientific
keywords: Best practices; Europe; Myocardial perfusion scintigraphy; Nuclear cardiology; PET; Quality of care; Radiation dose; SPECT