Current worldwide nuclear cardiology practices and radiation exposure: results from the 65 country IAEA Nuclear Cardiology Protocols Cross-Sectional Study (INCAPS)

Andrew J Einstein, Thomas N B Pascual, Mathew Mercuri, Ganesan Karthikeyan, João V Vitola, John J Mahmarian, Nathan Better, Salah E Bouyoucef, Henry Hee-Seung Bom, Vikram Lele, V Peter C Magboo, Erick Alexánderson, Adel H Allam, Mouaz H Al-Mallah, Albert Flotats, Scott Jerome, Philipp A Kaufmann, Osnat Luxenburg, Leslee J Shaw, S Richard UnderwoodMadan M Rehani, Ravi Kashyap, Diana Paez, Maurizio Dondi, INCAPS Investigators Group

Research output: Contribution to journalArticlepeer-review


AIMS: To characterize patient radiation doses from nuclear myocardial perfusion imaging (MPI) and the use of radiation-optimizing 'best practices' worldwide, and to evaluate the relationship between laboratory use of best practices and patient radiation dose.

METHODS AND RESULTS: We conducted an observational cross-sectional study of protocols used for all 7911 MPI studies performed in 308 nuclear cardiology laboratories in 65 countries for a single week in March-April 2013. Eight 'best practices' relating to radiation exposure were identified a priori by an expert committee, and a radiation-related quality index (QI) devised indicating the number of best practices used by a laboratory. Patient radiation effective dose (ED) ranged between 0.8 and 35.6 mSv (median 10.0 mSv). Average laboratory ED ranged from 2.2 to 24.4 mSv (median 10.4 mSv); only 91 (30%) laboratories achieved the median ED ≤ 9 mSv recommended by guidelines. Laboratory QIs ranged from 2 to 8 (median 5). Both ED and QI differed significantly between laboratories, countries, and world regions. The lowest median ED (8.0 mSv), in Europe, coincided with high best-practice adherence (mean laboratory QI 6.2). The highest doses (median 12.1 mSv) and low QI (4.9) occurred in Latin America. In hierarchical regression modelling, patients undergoing MPI at laboratories following more 'best practices' had lower EDs.

CONCLUSION: Marked worldwide variation exists in radiation safety practices pertaining to MPI, with targeted EDs currently achieved in a minority of laboratories. The significant relationship between best-practice implementation and lower doses indicates numerous opportunities to reduce radiation exposure from MPI globally.

Original languageEnglish (US)
Pages (from-to)1689-96
Number of pages8
JournalEuropean heart journal
Issue number26
StatePublished - Apr 21 2015


  • Aged
  • Cardiology
  • Clinical Protocols
  • Cross-Sectional Studies
  • Female
  • Global Health
  • Guideline Adherence
  • Humans
  • Male
  • Middle Aged
  • Myocardial Perfusion Imaging
  • Positron-Emission Tomography
  • Practice Guidelines as Topic
  • Professional Practice
  • Quality of Health Care
  • Radiation Dosage
  • Radiation Exposure
  • Regression Analysis
  • Tomography, Emission-Computed, Single-Photon
  • Journal Article
  • Multicenter Study
  • Observational Study
  • Research Support, Non-U.S. Gov't


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