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. 2018 Nov 1;39(41):3715-3723.
doi: 10.1093/eurheartj/ehy546.

Reduction in radiation exposure in cardiovascular computed tomography imaging: results from the PROspective multicenter registry on radiaTion dose Estimates of cardiac CT angIOgraphy iN daily practice in 2017 (PROTECTION VI)

Thomas J Stocker  1   2 , Simon Deseive  1   2 , Jonathon Leipsic  3 , Martin Hadamitzky  4 , Marcus Y Chen  5 , Ronen Rubinshtein  6 , Mathias Heckner  1 , Jeroen J Bax  7 , Xiang-Ming Fang  8 , Erik Lerkevang Grove  9 , John Lesser  10 , Pál Maurovich-Horvat  11 , James Otton  12 , Sanghoon Shin  13 , Gianluca Pontone  14 , Hugo Marques  15 , Benjamin Chow  16 , Cesar H Nomura  17 , Ramzi Tabbalat  18 , Axel Schmermund  19 , Joon-Won Kang  20 , Christopher Naoum  21 , Melany Atkins  22 , Eugenio Martuscelli  23 , Steffen Massberg  1   2 , Jörg Hausleiter  1   2 ; PROTECTION VI investigators
Collaborators, Affiliations

Reduction in radiation exposure in cardiovascular computed tomography imaging: results from the PROspective multicenter registry on radiaTion dose Estimates of cardiac CT angIOgraphy iN daily practice in 2017 (PROTECTION VI)

Thomas J Stocker et al. Eur Heart J. .

Abstract

Aims: Advances of cardiac computed tomography angiography (CTA) have been developed for dose reduction, but their efficacy in clinical practice is largely unknown. This study was designed to evaluate radiation dose exposure and utilization of dose-saving strategies for contrast-enhanced cardiac CTA in daily practice.

Methods and results: Sixty one hospitals from 32 countries prospectively enrolled 4502 patients undergoing cardiac CTA during one calendar month in 2017. Computed tomography angiography scan data and images were analysed in a central core lab and compared with a similar dose survey performed in 2007. Linear regression analysis was performed to identify independent predictors associated with dose. The most frequent indication for cardiac CTA was the evaluation of coronary artery disease in 89% of patients. The median dose-length product (DLP) of coronary CTA was 195 mGy*cm (interquartile range 110-338 mGy*cm). When compared with 2007, the DLP was reduced by 78% (P < 0.001) without an increase in non-diagnostic coronary CTAs (1.7% in 2007 vs. 1.9% in 2017 surveys, P = 0.55). A 37-fold variability in median DLP was observed between the hospitals with lowest and highest DLP (range of median DLP 57-2090 mGy*cm). Independent predictors for radiation dose of coronary CTA were: body weight, heart rate, sinus rhythm, tube voltage, iterative image reconstruction, and the selection of scan protocols.

Conclusion: This large international radiation dose survey demonstrates considerable reduction of radiation exposure in coronary CTA during the last decade. However, the large inter-site variability in radiation exposure underlines the need for further site-specific training and adaptation of contemporary cardiac scan protocols.

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Figures

Take home figure
Take home figure
Reduction of dose-length product from coronary computed tomography angiographies and variation between study sites. Left: box plots illustrate dose-length product of all coronary computed tomography angiographies. Right: variability of median dose-length product (± interquartile range) between the study sites in the 2007 and 2017 dose surveys, respectively.
Figure 1
Figure 1
Differences in dose-length product of coronary computed tomography angiography by gender (A) and computed tomography manufacturer (B).
Figure 2
Figure 2
Effect of dose saving strategies with tube potential reduction (A), scan mode (B), and application of iterative image reconstruction (C) on dose-length product in coronary computed tomography angiography.
Figure 3
Figure 3
Independent predictors of radiation dose from coronary computed tomography angiographies. Change of radiation dose in coronary computed tomography angiography by independent patient and scan-associated factors as identified by a multivariable linear regression analysis. Retrospective electrocardiogram-gated low-pitch helical and prospective electrocardiogram-triggered high-pitch helical scan modes were compared with the axial scan technique.
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