cardiac imaging report

8/17/2019 Cardiac Imaging Report

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Cardiac Imaging

AReportfromtheNationalImagingBoard

March2010.

Gateway reference number: 13859


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Foreword

Wehopethisreportwillprovetobeaveryusefulresourcetostimulatedevelopmentofeffectivecardiacimagingservices.Thereportrepresentsthecurrentstatusofarapidly

evolving fieldof imagingand isevidencedwheresuch informationexists.Ithasbeenproduced in response to numerous requests for information on cardiac imagingservices.ThereportacknowledgesthattheCardiacNetworksareatdifferentlevelsofdevelopmentandareconfigureddifferentlyacrossEngland.2010-11 will see tougher economic circumstances. The report outlines manyopportunitieswhichcanbeused to transformcardiacservices and support theQIPP(quality,innovation,productivityandprevention)agenda.ItillustrateshowtheNHScanimprovequality,safetyandproductivitywhileworkingacrossdisciplinestodeliverbettercareforcardiacpatients.

Noattempthasbeenmadetoreplicatethedetailtobefoundinatextbookofcardiacimaging, butanoverviewofcardiacimagingservices isprovidedwith a focuson theinformationthatwouldbebeneficialforcommissionersoftheseservices.The document has been produced by a complex group of stakeholders from manydifferent disciplines and we are indebted to them for giving up their time and theirextensiveknowledgeandexpertisetomakethisreportpossibleThisdocumentisproducedata timewhentheevidencebaseforfunctionalimaging issufficientlyrobustthatproceedingtoelectivecardiacinterventionwithoutpriortestingisincreasinglyseentobeinappropriate.

Professor Roger Boyle Dr Erika Denton

National Director for National Clinical Lead for

Heart Disease and Stroke Diagnostic Imaging

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Contents

Page

5 Summaryofkeypoints6 Background

8 WhatdowemeanbyCardiacImaging?

13 TheCardiacImagingModalities

CoronaryAngiography

CardiacCT

Echocardiography

CardiacMRI

NuclearCardiology

23 ServiceDeliveryinCardiacImaging

26 ReportingofCardiacImaging

27 FinancingtheService

29 ChoiceofTest

Modalitycomparisontable

36Theroleofcardiacimaginginspecificclinicalpathways:

Chestpainofrecentonset

Chronicstableangina

39 Conclusions

40 AppendixAEquipmentSpecification

45 AppendixBCardiacImagingRadiationDose

47 AppendixCInnovativePracticeExamplesfromtheCardiacNetworks

t

Non-InvasiveImagingPathway

ImprovedQuali yStandardsforEchocardiography

ImprovedDataCollectionandPlanning

ImprovedCardiacDataTransfer

PACS/ITCaseStudy

66 ReferencesandBibliography.

71Acknowledgements

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Summary of key points

Cardiac imaging services should ideally be specifically and separately

commissioned. The key principle behind commissioning cardiac imaging should be that the

serviceisofdemonstrablyhighqualitywhereverandbywhoeveritisdelivered. Apoorlyperformedimagingproceduremayleadtopatientharmlessdirectlybut justaseasilyasapoorlyperformedinvasiveprocedure.

Wherestandardsforaccreditingindividualsanddepartmentsexistthesecouldbe

usedasabasisforsupportingcommissioning.

There are a variety of different imaging tests which will provide answers tocardiacimagingclinicalquestions. Thesepathwayswillvaryaccordingtolocalexpertise,experienceandequipmentavailability.

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Background

1. This reporthas beenprepared byaspecially convenedsub-groupof theNational

ImagingBoardtoprovideadviceonCardiacImagingServices.Thereportdiscusses

wheretheuseofparticularimagingmodalities,forspecificgroupsofpatients,maycontribute to improvements in Quality, Innovation, Productivity and Prevention(QIPP). Evidence is cited where it exists, whilst recognising that someemergingtechnologiesdonothaveanestablishedevidencebase.

2. Thisreportcontainsinformationforthoseprofessionalsworkingin,commissioningor

interfacingwith,cardiacimagingservices.Thiswillincludethosewhoare:

• responsibleforcommissioningcardiacimagingservices

• managingcardiacimagingservices

• involvedintheeducationandtrainingofstaffwhowillbeworkingwithpatientswhorequireimaging

• involvedinthecareofpatientswhorequireimaging• involvedinsupportingthedevelopmentofcrossorganisationalpatientpathways

e.g.CardiacNetworks

3. Thekeyprinciplebehindthecommissioningof cardiacimaging shouldbethat theservicedeliveryisofdemonstrablyhighqualityirrespectiveofwhereorbywhomitisdelivered.Apoorlyperformedfunctionalimagingproceduremayleadtopatientharmless directly but just as easily as a poorly performed invasive procedure.Wherestandardsforaccreditingindividualsanddepartmentsexistthesecouldbeusedasabasisforsettingcommissioningstandards.

4. While diagnosis and prognosis inheartdisease are important, the mainpracticalgoalofinvestigationisidentifyingwhichpatientswillbenefitfromspecifictherapies,for example coronary angioplasty, bypass surgery, valve replacement, cardiacresynchronizationtherapyordefibrillators.Itiswiththisinmindthatimplementingastreamlined process for the management of patients with known or suspectedcoronaryarterydiseaseusingappropriatetestsremainsattheforefrontofthisreport.

5. This reportdescribes therole that each imagingmodalityhasin investigating and

managingapatientwithknown,orsuspected,CoronaryHeartDisease(CHD)*.6. Itacknowledgesrecentimprovementsintechnologythatallowimprovedanatomical

andfunctionalassessmentofCHD.Indoingsoitdoesnotdefineadefinitiveimagingpathway,but,recognisestheneedforlocalsolutionsaccordingtotheexpertiseandexperienceofanexistingworkforceandcurrentlyavailablefacilities.

CoronaryHeartDisease (CHD) – narrowing orblockageof the coronaryarteriesby the fattymaterialtermedatheroma,whichmay leadto angina,coronarythrombosisorheartattack,heart failureand/orsuddendeath.

(NIAP–NationalInfarctAngioplastyProject)

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7. Delivery of cardiac imaging services across England varies considerably and thevarioussuccessfulapproachesandmodelsofinvestigationofthesepatientsadoptedcurrentlywithintheNHSaredescribed.

8. Thereportalsoexploresalternativesforimagingandconsidersthelikelypresentingsymptomsforthispatientgroup.Descriptionsofthespecialisedequipmentneededtoprovidetheseservicesandthenecessaryworkforceareincluded.

9. Atatimeofeconomicconstraintfundingneworexpandingexistingservicesismore

challenging.Thisisrecognisedwithadiscussionofthecurrentfundingissuesandtariffforthisdiagnosticarea.

10. Appendix C provides current examples of service delivery from different cardiac

networks. These explore the challenges and solutions found at a local level todeliveryofeffectivecardiacimagingservices.

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What do we mean by Cardiac Imaging?11. Coronaryangiography (CA)was introduced in the1960’sandhasformanyyears

been the gold standard for confirming the presence of atheromatous coronaryobstructionandplayedacentralroleinthemanagementofpatientswithcoronaryarterydisease. Foramoredetailedexplanationofthis techniquepleaseseepage13. However, recent developments in non-invasive testing with establishedfunctional studies such as stress echocardiography (SE), myocardial perfusionscintigraphy (MPS) and cardiac magnetic resonance imaging (CMR) are nowconsideredmorethanscreeningtests,sincetheyalsoprovidevaluableinformationondiseaseseverityandpatientprognosis.

12. Functional imaging¹ remains underused in the UK, despite echocardiography

machines,gammacamerasandMRequipmentthatcouldbeconfiguredforcardiac

work being available in most hospitals. Thesemodalities have the potential fordirectingcoronaryangiographymoreeffectivelytowardsthosepatientsmostlikelytorequire invasive intervention. Studies have shown that MPS, SE and CMR canpredict the likely symptomatic and prognostic outcome after subsequentrevascularisation.PatientswithnormalMPScanbereassuredthatfurtherinvasiveinvestigationisunlikelytoleadtoeithersymptomaticorprognosticbenefit,eveniftheydohavenarrowingofcoronaryvessels.

13. There have been recent developments in anatomical imaging, particularly in

computerised tomography(CT)whichhaveincreasedthepotentialshiftawayfromcoronary angiography. The extent to which this impacts on the need for CA will

dependonmanyfactorsandthesearediscussedlater.

The Technology and Equipment

14. All cardiac imaging departments should develop robust well documentedprogrammes for equipment quality assurance, timely equipment replacement,appropriate IT systems, image archiving facilities and, for many, telecardiology. Advances in cardiac imaging equipment are rapid and likely to continue swiftly,particularly for the newer imaging modalities. Benefits of newer equipment caninclude:

• better,moredetailedandmoreusefuldiagnosticinformationtotargettherapy

moreeffectively• moreefficientrapidimageacquisition,workflow,analysisandreporting

• rapidandwidespreadavailabilityofresultstoclinicians

• replacinginvasiveprocedureswithnon-invasivetests

¹Functional Imaging (FI) reveals physiological activity within a tissue or organ bydetecting or measuring changes in metabolism, perfusion, chemical composition ormechanicalfunction.

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15. FIhastheabilityto:

• substitute tests using ionising radiation for tests using non-ionising imagingwhereappropriatei.e.provideddiagnosticaccuracyismaintainedorimproved.

ForexampleuseSEorCMRinsteadofCA,MPSorCT.• permit development of image guided techniques to replace and enhance

existingmedicalandsurgicaltreatments.

16. Allimagingequipmentwearsoutovertime,butitsexpectedlifemaybeshortenedasa result of improvements in technology,particularly fornewer imagingmodalities.Theexpectedusefullifeofimagingequipmentdependsupon:

• Age,intensityofuseandcaretaken(particularlyforecho/ultrasoundprobesandMRIcoils)

• Availabilityofspareparts

• Newimagingprotocols(e.g.CMRperfusionormyocardialviabilityassessment)

mayrequiremoremodernequipment• Regularequipmentmaintenance

• Equipmentupgrades(particularlysoftware,computers)

• Radiationdosebecausehigherdosetechniquesdecreasethelifeofanx-raytube,especiallyinCT

17. For service planning purposes reasonable replacement ages for cardiac imagingequipmentarecurrentlyapproximately:

Echocardiographymachines,5yearsSPECTimagingequipment,7yearsComputedtomography(CT)equipment,7years

CMRequipment,7years.CoronaryAngiography,7years

18. Asequipmentagesandnewer,oftenfaster,equipmentisavailable,businesscasesforearlierreplacementthan these recommendationsmaybe themostappropriatestrategy as the existing equipment may be inefficient or manufacturers may nolongercarrysparepartstosupportongoingmaintenance.

19. Maintenance and quality assurance protocols for imaging equipment, including

calibration of equipment by appropriate personnel, up-to-date safety inspectioncertificateswhereneeded,andinspectionbyqualifiedmedicalphysicspersonnelfor

qualitycontrolmustbeinplace.

20. MoredetailonequipmentspecificationscanbefoundatAppendixA

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The Workforce

21. All cardiac imaging requires a dedicated, multidisciplinary, appropriately trainedworkforce.

22. It is likely there will be an increase in cardiac imaging services to meet future

populationdemand and thiswill require anexpansion of staffnumbersacrossalldisciplines.It isanticipated thatmedicalconsultantpostholders incardiacimagingwillcomefromabackgroundofcardiology,radiologyornuclearmedicine.Thiswillrequirecarefulconsiderationandco-operationbetweentheprofessions,particularly,whereequipmentisshared.Sharedtrainingisalsobestpracticetoproduceanewbreedofskilledcardiacimagingclinicians.Appointmentpanelsshouldaimtohaveappropriateprofessionalrepresentationtoensurethatmultidisciplinaryinvolvementis maintained in the delivery of cardiac imaging services. There should be adesignated team leader, who will take responsibility for ensuring that the team

providescarewhichissafe,effective,andefficient.23. In 2003Hackett and a working group of the British Cardiac Society published a

reportonCardiacWorkforceRequirements.The recommendationat that timewasfor35cardiologistspermillionheadofpopulation.Theyalsodescribedanincreasedneedforcardiacphysiologists.Furtherworkisbeingundertakentoupdatethisreportbut the issues identified in2003 broadly remain the samebutwith an increasingneedforcardiacimagingexpertiseinlinewithevolvingtechnologyandlessinvasivediagnosticinvestigation.

Training Standards

24. Radiologistsandcardiologistsreceivecoretrainingincardiovascularphysiologyandimaging. However, as cardiac CT and MRI emerge it is unlikely that sufficientexperience will have been obtained during basic training in either specialty, andspecific training should therefore be obtained prior to independently performingcomplexcardiacimaging.

Cardiac CT Angiography (CCTA)25. This is technically demanding. To effectively provide a clinical service, provision

shouldbemade for at least twoLevel2 or equivalent trainedclinicians (seeTheBritishSocietyofCardiovascular Imagingguidelines) inanyoneinstitution.Whilstnetworkingbetweenhospitalswithremotereportingcanprovideareportingservicethere isa current need for direct supervision at the time of image acquisition forCCTA. Ideally both a cardiologist and radiologist should be involved in providingsuchaserviceassuchapartnershipissynergistic.Iftheserviceistobeprovidedbycardiologistsalone,provisionshouldbemadeforasecondreviewbyaradiologisttrained in thoracic imaging, asupto20%ofCCTA’shavesignificantnon cardiacpathology

Radiographers and Clinical Technologists

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26. There are, at present, no formal training requirements in cardiac imaging forradiographicstaff,CCTAandCMRplacesimilartechnicaldemandsonthesestaffandideallyatleast2radiographersortechnologistsinanyorganisationundertakingthese techniquesshouldobtainexpertiseinCCTAorCMRbya secondment toa

centreproficientintheseimagingmodalities.27. Elementsofcardiacimagingareundertakenbycardiactechnologists,radiographers

andotherhealthcarestaffwhoarenotregisteredmedicalpractitioners.Theprocessofacceptanceofareferralforaclinicalimagingstudyandtheperformanceoftheprocedure can be delegated to appropriately educated and trained healthcarepractitionersunderlocalprotocolsandclinicalgovernancearrangements.

28. There isa shortage of technical staffskilled incardiac imaging.Effortsare being

madeto increase the numberofstaff in trainingwhichmay allow existing staff tospecialise and undergo further training in cardiac imaging. Additionally, role

extension initiatives to trainmembersof thenon-medicalcardiac imaging team inskillspreviouslyonlyundertakenbydoctorsarebeingexplored.29. Increasingnumbersoftraineecardiologistsspecialiseincardiacimaging,including

echocardiography and, provided there is a corresponding increase in skilledtechnicalstaff,thisshouldallowforexpansionofstressechocardiographyandotherareas ofCI. However, the current plans for Modernising ScientificCareers mayexacerbatetheshortageofhighlyskilledtechnologistsincludingechocardiographersintheshorttermduetoproposedchangestothetrainingmodelandaperceivedlackofclarityaroundcareerprogression.

Cardiac Physiologists

30. Cardiacphysiologistscarryoutanextensiverangeofdiagnosticand interventionalprocedures for patients with known or suspected heart disease. They workindependentlywithpatientslargelywithout directclinicalsupervision.Cardiologistsand other specialists use the informationgathered by cardiacphysiologistswhenmakingadiagnosisandprescribingappropriatetreatment.

31. Workforce Review Team (WRT) analysis (2009) suggests demand for cardiac

physiologyservicesand thereforeanappropriateworkforceis increasing.This isaresultofincreasingworkloadindiagnosticstudiesforcardiacpathways.

32. Althoughthereislimitedaccuratedataonthenumberofcardiacphysiologists,WRT

evidencegatheringsuggeststhatthereisasignificantnationalshortage.“Skillmix”initiatives including the use of assistant/associate practitioner grades in nonspecialistsupportrolesmayincreasetheworkforce.

Clinical Scientists and Technologists.33. All cardiac imaging modalities are supported by Clinical Scientists and

Technologists.These staff groups provideadvice on equipment specification andprocurement,imagequality,radiationdose,staffsafetyandqualityassurance.They

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alsocarryoutarangeofservicesincludingequipmentcommissioning,qualitycontroltesting, image acquisition and image processing. Formal roles include : TheRadiation Protection Adviser (RPA) – radiation safety and quality assurance, theMedical Physics Expert(MPE) – to advise on image quality and optimisation for

modalities using ionising radiation and an MR Safety adviser in accordancewithMHRADB2007(03)

Access and Choice

34. FollowingtheNHSNextStageReview,theWRTexpectthattransferoftechnologiesand competencies fromone sector toanother (e.g. secondary toprimary care) islikelytotakeplaceoverthenextdecade.Thishasimplicationsforfuturetrainingof,and increased roles particularly for, cardiac physiologists in the community. Thedevelopment ofassistant and associatepractitioners tosupportspecialist imagingroles and the emergence ofconsultantposts for cardiac physiologyservices isanaturalprogressiontoenhancecareeropportunitiesaswellasincreasecapacityin

thedepartment.Additionalroles,suchasdedicatedclericalsupport,arenecessarytoincreasetheclinicaltimespentbyclinicallytrainedstaffindirectpatientcare.Accreditation, Certification and Re-validation

35. Following publication of the report “Trust, Assurance and Safety”, the GeneralMedicalCouncil (GMC), theHealthProfessionsCouncil (HPC)andtheNursing&MidwiferyCouncil(NMC)areintheprocessofreviewingtheregulationofhealthcareprofessionals. Fundamental to the principle of professional self regulation is theactive participation of the registered individual in Continuing ProfessionalDevelopment.

36. FormedicalpractitionersundertakingContinuingMedicalEducation(CME),trainingneedsaredetailedinthecardiologyandradiologysub-specialtycurricula.Althoughcompletion of UK training results in entry onto the specialist registry, additionalnationalandinternationalsubspecialtystandardsareavailable.

37. Clinicians responsible for cardiac imaging need to keep knowledge, clinical andteachingskillsup-to-date.Forcardiacimaging,requirementsdependonthespecificimagingmodalityandlevelofpre-existingtraining.

38. All staff within a cardiac imaging department should have been trained to an

appropriate level for their jobaccording tonational and/or international guidelines.

Evidence of CPD is a core requirement of re-validation (GMC) and renewal ofregistration (HPC) thus dedicated time for CPD is necessary. CPD support isparticularly important for newgraduate staff to allow them to develop the levelofskillsrelevanttotheirrole.Competencemustbemaintainedandthisshouldincludeup-to-datetraininginresuscitationandthemanagementofadversereactions.

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The Cardiac Imaging Modalities

Coronary Angiography

Introduction

39. Coronary angiography is an invasive technique to image the coronary arteries.Catheters are inserted under local anaesthetic via the femoral, radial or brachialarteriesanddirectedusingx-rayguidancesothattheirtipslieinthemouthofeitherthe left or the right coronary arteries which arise from the ascending aorta.Radiographiccontrast is then injectedinto thecoronary arteries tovisualisebloodflowand identifyany narrowingor blockage that could becausingsymptoms. Inexperthandstheriskofaseriouscomplicationincoronaryangiographyisaround1in 1000. Risksmay be higher in elderly patients who are ill with other ongoingdiseaseprocesses.

Indications

40. Coronaryangiographyisindicatedintheassessmentofchestpaininthosewithahighpre-testlikelihoodofcoronarydisease,inthosewithadiagnosisofanginaandongoingsymptomsorahighriskevaluationonfunctionalimaging(showingevidenceofirreversibleischaemia)andinthosepresentingwithanacutecoronarysyndromeor myocardial infarction. A proportion of these patients can go directly to atherapeuticprocedure.DiagnosticAngiographyisnotusuallyusedasa‘firsttest’forstablepatients.Itshould(usually)beofferedinthesettingofanabnormalfunctionaltestoranabnormalimaginginvestigationsuchascardiacCT.Currentlyitistheonlyinvestigation that can be used to plan Percutaneous Coronary Interventions orCoronaryArteryBypassGraftsurgery(CABG.)Coronaryangiographyvisualisesthe

lumenofthecoronaryarteries.Combinedwithintracoronaryultrasounditcanalsobeusedtoassessthewallsofthecoronaryarteriesandcombinedwithintracoronarypressurewirestudiestoassessthefunctionalsignificanceofanarrowing.

Equipment

41. Coronary angiography requires a fully equipped and staffed catheterisationlaboratory.This isusuallyadedicatedcardiaclaboratorybutmaybe sharedwithvascularradiology.Fullresuscitationfacilitiesarerequired.

Workforce

42. Coronary angiography requires a fully trained operator, usually a cardiologist or

sometimes a cardiac radiologist. Trained support staff are also necessary.Traditionally these have been radiographers, cardiac technicians and nurses butsome units arenow developing highly skilledgeneric catheter laboratoryworkerswithacombinationofexpertise.

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Cardiac CT

Introduction

43. Cardiac CT is a non-invasive x-ray based technique using conventional multi-detectorCTscanners.Theneedto“freeze”cardiacmotionnecessitatestheuseofECGgatingrequiringadditionalhardwareandsoftwarewhencomparedtotraditionaldiagnosticCT.

44. The time taken toperforma cardiacCT isapproximately10minutesalthough the

actualdataisacquiredoveronlyafewseconds.Intravenousiodinatedcontrastisgiven (CT coronary angiogram) although for a coronary calcium assessment(coronarycalciumscore)thisisnotrequired.Patientsareoftenpre-medicatedwithoralorintravenousbetablockersimmediatelypriortothescanbutthereisnootherpatient preparation. Given the speed of image acquisition cardiac CT is well

toleratedandroutinelyperformedonoutpatientsaswellasmoreacutelyunwellin-patients.

45. The strength of cardiacCT is its ability to provide high resolution images of the

coronary arteries and cardiac morphology non-invasively. Unlike invasiveangiographyCTprovidesinformationaboutthevesselwallaswellasthelumenandcan detect early atheroma before vessel narrowing. It has a very high negativepredictive value (approaching 100%) effectively excluding coronary disease inpatientswithanormalscan. Coronarycalciumscoringidentifiescalcifiedcoronaryatheroma.Additionalinformationonventricularfunctionandvalvefunctionaswellasmyocardialperfusionandscarringmaybeobtained.CThaslimitations.Forsome

patientstheanatomymakesitdifficulttoimagethecoronaryarteriesintheirentiretyandforpatientsinatrialfibrillationECGgatingcanbedifficulthowevertheanatomycanbemoreeasilydiscernedthanatcoronaryangiographyinsomepatients.

46. Radiation doses for cardiac CT have fallen substantially with recent technical

advances. Well-trained staff using appropriate techniques and equipment willroutinelydeliverdosesbelowthoseofinvasivecoronaryangiography.

Indications

47. Primaryindicationsare:

•Theevaluationofcoronaryarterydiseaseinpatientswithchestpainandalowto

intermediateriskofcoronarydiseaseandparticularly theabilityto ruleoutCADand therefore prevent unnecessary admissions of patients with undiagnosedchestpainandunnecessaryinvasivecoronaryangiographyinpatientswithlowtointermediateriskofCAD(NICE2009).

•Investigationofanomalouscoronaryarteries.

•Evaluationofcoronaryarterybypassgrafts.

•Evaluation of cardiac anatomy (including prior to pulmonary vein isolationprocedures).

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48. Secondaryindicationsinclude:

• Leftandrightventricularfunctionandvolumeanalysis.

• Valvemorphologyandfunctionassessment.

• Evaluationofcongenitalheartdisease(particularlyinpatientswithcontra-indicationstocardiacMRI).

Equipment

49. CardiacCTisgenerallyundertakenusingCTscannersalsodesignedforafullrangeof non-cardiac investigations. Technology is changing rapidly with consequentbenefits of reduced radiation exposure and increased diagnostic accuracy. Theminimumrecommended requirement forcardiacCTangiography is64-slicemulti-slicescannerwithassociatedcardiachardwareandsoftware.Bothprospectiveandretrospectivecardiacgatingtechniquesareneeded.

Workforce

50. Workforce requirements are identical to those of a general CT department.Scanning is performed by one radiographer usually with the assistance of aradiographic assistant or second radiographer. Additional staff are of benefit toincreaseworkflow. Scansaresupervised indirectlyordirectly byanappropriatelytrainedclinician. It isessential thata report isobtained coveringboth thecardiacandthoracicanatomy.Reportingofscansisoptimallyperformedbyacollaborationof appropriately trained Cardiologist and Radiologist, and this practice isencouraged.SolereportingofcardiacCTisappropriateiftheyaresuitablytrainedinbothareasandthatsuitableclinicalgovernancestandardsareadheredtosuchas

auditofresultsandexternalreviewofcases.

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Echocardiography

Introduction

51. Echocardiography uses ultrasound to examine the structure and function of the

heart. No ionisingradiation is involved andtherisks ofdiagnosticultrasoundareextremely low. Images can be obtained through two routes: transthoracic andtransoesophageal usinga specialisedendoscopicprobe.A standard transthoracicexamination takes around 30-40 minutes including reporting time. Stressechocardiography (where a transthoracic examination is carried out while thecirculation is stressed) and transoesophageal echo take around 45-60 minutes.Echocardiographyproduces2dimensional imagesof theheart(3-D isalsowidelyavailable)withafastframerateallowingaccurateestimationofbothstructureandfunction. TheadditionofDoppler imagingprovides informationaboutblood flowand indirect pressure measurement. 2-D echocardiography with Doppler is anessentialtoolforanycardiologydepartment.

Indications

52. Indications for echocardiography are very broad and include suspectedabnormalities of cardiac structure, e.g. atrial septal defect and suspectedabnormalitiesofcardiacfunction,e.g.heartfailure,valvedisease.Echoisvaluableforassessmentof leftventricularsystolicanddiastolicfunctionandcanbeusedtotrack changes over time. Valve abnormalities are well demonstrated, providinginformationaboutmorphologyanddegreeofhaemodynamicdisturbance.

53. Stressechocardiography(seebelow)isindicatedinchestpainwithanintermediate

probabilityofcoronarydisease,intheassessmentofmyocardialviabilityandforthe

assessmentofrecurrentchestpainafterrevascularisation.Equipment

54. Echocardiography requires a dedicated ultrasoundmachine with specific cardiacsoftware.Generalultrasoundmachinesarenotsuitable.Machinesareportableandexaminations can be performed at the bedside or in an outpatient setting. Fortransoesophageal echocardiographyadedicatedprobeandsoftwarearerequired.Imagesshouldbestoredinadigitalarchivingsystemwiththeirverifiedreports.

Workforce

55. Most transthoracic echocardiography is performed and reported by highly skilledphysiologists. Transoesophageal and stress echocardiography require medical

supervision.Thereisanationalshortageofsuitablyskilledtechnicalstaff.Standards

56. Standards for individualanddepartmental accreditation inechocardiography havebeendevelopedbytheBritishSocietyofEchocardiography( www.bsecho.org).

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Stress Echocardiography

57. Stress echocardiography uses ultrasound to image the heart while it is beingstressed.Areasoftheheartthatbecomeshortofoxygenonstresscanbedetected

as they fail to contract normally. Stress may be pharmacological (usuallydobutamine)orexerciseinduced.Forpharmacologicalstressaninfusionpumpisrequiredtodeliverdobutamineandmanyunitsalsousea transpulmonarycontrastagent to improve visualisationof the left ventricle. Full resuscitation facilities arerequired.Differentmyocardialresponsestostressechoenableinfarction,ischaemiaandhibernationtobedistinguished.

Transoesophageal Echocardiography

58. TransoesophagealechoissimilartouppergastrointestinalendoscopyandisusuallyperformedunderlightconscioussedationasadaycaseprocedurebutmayalsobeperformedinventilatedpatientsonITUorin theatre.Resuscitationfacilities,piped

oxygen,suctionandasaturationprobearerequiredaswellasasuitablerecoveryarea.

Strengths and weaknesses of Echocardiography:

59. Echo is relatively cheap and transthoracic examinations can be carried out bycardiacphysiologists. The equipment ismobile and canbe taken to the patient.Echodoesnotrelyonionisingradiationsoisparticularlysuitableforpatientswhorequirerepeatedimagingovertime.

60. Some patients give poor transthoracic images (“poor echo windows”) and the

information derived can therefore be limited. The use of echo contrastmaterialimprovesimagequalityinthesepatientsbutrequiresanintravenousinjection.Echoreliabilitydependsontheexperienceofthepersonreportingtheimagesandthisismoresignificantlythecaseforstressecho.

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Cardiac MRI

Introduction

61. Cardiac(or cardiovascular)MRI, known asCMR,usesasuitableMRIscannerto

imagetheheart.Itisasafe(beingradiation-free),non-invasivetechnique.Therearemultiple differentCMR techniques that can bedonewithin one scan for differentindications. Less thanhalfofall CMRscansare for coronary artery disease, forexample. Most (90%) of patients will be outpatients, but it is also valuable forinpatients,especiallywhenplanningcomplexinterventions.Therearesomecontra-indications to CMR, most commonly pacemakers, implantable defibrillators orintraocular metallic objects. Problems such as arrhythmias have largely beenovercomeby technicaladvances allowingmore rapid imageacquisition.Allstentsandsurgicallyreplacedcardiacvalvesaresafeat1.5and3Tfieldstrengths.

62. Severerenalfailure(GFR


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• Other: Coronaryanomalies arewelldemonstrated byCMR techniquesbutallother anatomical coronary indications are better done by CT or invasiveangiography.

Equipment

64. Most centres will use general MR equipment, but there will be some dedicatedscannersdoing justCMR. Almost anymodern, closed boreMRIscannercan beupgraded for cardiac MRI. The British Society of Cardiac MR (BSCMR) has aspecifiedminimumequipmentlevel,includingscannerspecification,sequencesandanalysisequipment.

Workforce

65. ACMRserviceshouldhaveanominatedclinical lead,anominatedtechnical leadandappropriatelytrainedmedicalandtechnicalstafftodelivertheservicewhoaretypically radiographers but may have echocardiography or cardiac physiologist

backgrounds.CMRmaybeprovidedbycardiology,radiologyor,ideally,asajointservice.

Standards for service delivery

66. CMRiscomplexandaqualityservicetypicallyrequiresaminimumof300scansperyeartomaintaincompetency.Largecentresmaydo2000scansayear.Therearelikelytobeanestimated50centresintheUK,includingallcardiacsurgerycentres.Standard scanning and reporting protocols areavailable from Society forCardiacMR,(SCMR)andUKservicestandardsareavailablefromBSCMR.

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Nuclear Cardiology

Introduction

67. Nuclear Cardiology uses an injection of a small dose of a radioactive tracer, orradiopharmaceutical,toimagetheheart.Conventionalnuclearmedicineusessinglephoton emitting radionuclides but positron emitting radionuclides provide higherresolutionandpotentially quantifiable information in centreswith suitable PositronEmissionTomography(PET)technology.Dependinguponthetypeoftracerused,different information is obtained, but nuclear imaging provides mainly functionalinformationsuchasmyocardialviabilityandperfusionandventricularfunction.Fullresuscitationequipmentisrequired.

68. Myocardial PerfusionScintigraphy (MPS) is themost commonly performed stress

functional imaging technique. The tracersusedare takenupby viable (healthy)

myocardiuminproportiontoperfusion.Theinjectionsaregivenduringsomeformofcardiovascular stress, which might be treadmill or bicycle exercise orpharmacological stress. Pharmacological stress isparticularlyvaluable inpatientswhoareunabletoexercisemaximally.

69. Theimagesareacquiredusingagammacamera,whichrotatesaroundthepatient

toacquiretomographicimagesusingsinglephotonemissioncomputedtomography(SPECT).Twosetsofimagesarenormallyacquiredafterstressandrestinjectionsof tracer, since the resting imageprovides information ofmyocardial viability andchangesbetweenstressandrestimagesreflectchangesinperfusionanduptakeoftracerdependantonthedegreeofischaemia.Thestressandrestimagescanbe

acquiredeitheronthesameorseparatedays.70. Radionuclide ventriculography (RNV) is another well established and validated

technique in which the blood is labelled with technetium 99m. It is sometimesreferredtoas“multigatedacquisition”orMUGAbutthetermRNVispreferred.ECG-gated imagesof theventricularbloodpoolsprovidequantitativeinformationof leftandrightventricularfunctionsuchasejectionfractionandregionalfunction,anditisparticularly suited toassessing theregional timingofcontraction. The imaging isconventionallyplanarbut,increasingly,SPECTisusedtoprovidethreedimensionalinformation.

71. CardiacPositronEmissionTomography(PET)ismainlyconfinedtoresearchcentres

becauseofthehighcostofPETcamerasandtheneedforanon-sitecyclotrontogenerate thevery short-life radiopharmaceuticals forsome types ofPET imaging.Theincreasingavailabilityoffluorine-182-fluoro-deoxy-glucose(FDG)PETimaginginoncologymayleadtogreateruseofcardiacPETbecauseoftheadvantagesofhigherresolutionandpotentiallyquantifiableinformation.FDGisavailablewithoutacyclotronanditcanbeusedtoassessmyocardialviabilityandventricularfunction.Rubidium-82isbecomingavailablefromageneratorwithoutacyclotronanditisan

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alternativetoMPSforperfusionandviability.Nitrogen-13ammoniaandoxygen-15waterforperfusionimagingareonlyavailablewithanon-sitecyclotron.

Indications

72. MPSisprimarilyusedtodetect,localizeandsizeareasofinducibleischaemiaandmyocardialviabilityinpatientswithknownorsuspectedcoronarydisease. Abnormalperfusion(inducibleischaemia)usuallyindicatesobstructivecoronarydiseaseandtheextentanddepthoftheischaemiacorrelateswiththelikelihoodof futurecoronary events. Itcan thereforebe used todiagnose and localisedisease,totriagepatientsbetweenmedicaltherapyandrevascularisation,andtoassessriskbeforenon-cardiacsurgery.Abnormalviabilityimagesdiagnoseandsizemyocardialinfarctionand,withECG-gating,leftventricularfunctioncanalsobeassessed.Patternsofviability,perfusionandfunctioncanbeusedtodetect hibernating myocardium, which may benefit from revascularisation inpatientswithheartfailure.

73. MPS isan integral partofdiagnosticandmanagementalgorithms.NICEhasappraisedMPSforpatientswithanginaandmyocardialinfarctionandfoundittobeeffectiveandcost-effectiveinthissub-setofpatients.http://www.nice.nhs.uk/ta073.

74. AsignificantstrengthofRNVisitssimplicity,accuracyandreproducibilityforthe

assessmentofleftventricularfunction.Itisthereforemostcommonlyusedtomonitor function in patients receiving cardiotoxic chemotherapy althoughechocardiographyisanalternative.AssessmentofsynchronicityofcontractionbyRNVmaybecomeusefulinpatientsbeingconsideredforresynchronisationpacing (CRT). The detection and measurement of shunting in patients withcongenital heart disease is well validated but it is being replaced by MRIbecauseoftheadditionalanatomicalinformationgainedfromCMR.

Advantages and Disadvantages

75. NuclearmedicineexpertiseiswidelyavailableintheUKandthetechniquesarewellvalidatedwithextensiveevidencetosupporttheiruseinarangeofclinicalsettings. The equipment required is relatively inexpensive and there is thepotentialtoreducecostswithhighpatientthroughput.

76. However nuclear medicine images have relatively low spatial and temporal

resolution and the procedures involve exposing patients to low amounts of

ionizing radiation, albeit decreasing as a result of hardware and softwaredevelopments. Perhaps the most important limitation has been theconcentrationof nuclear imagingexpertiseoutside thecardiologydepartmentwithhistoricallylessmultidisciplinarycollaborationthanidealtoprovideclinicallyrelevantinterpretation.Thepracticalandpoliticallimitationsprobablyaccountinpartfortheunder-provisionofnuclearcardiologyservicesin theUKcomparedwithinvasivecardiacinvestigation.

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Equipment

77. A single cameranuclearcardiology department occupies approximately 65m²and a general purpose gamma camera can acquire good quality cardiacimages.Howeveradedicatedcardiacgammacamera(approximately£200,000)

canbeparticularlyeffectivewhendemandissufficient.ECG-gatingisessentialand attenuation correction is desirable. Radiopharmaceuticals can either beprepared on-site or purchased from a commercial radiopharmacy. Stressfacilities should accommodate both dynamic exercise and pharmacologicalstress.Dedicatednuclearmedicineworkstationsandimagestorageareusualsince current PACS systems cannot display nuclear cardiology imagesadequately.

Workforce

78. Cardiovascular stress must be led by an appropriately trained healthcareprofessional andclinicalnurse specialistsare increasingly takingon this role.

Imageacquisitionisbyanuclearmedicinetrainedradiographerortechnologist.Quality control and other technical aspects require the input of a medicalphysicsexpert(MPE).Radiationprotectionrequiresaspecialistadvisor(RPA)whomightbethesameindividualastheMPE.Reportingisusuallyledbyacardiologistwithradionuclideimagingexpertise,anuclearmedicinephysicianoraradionuclideradiologist,withcollaborativereportinginsomecentres.

Existing Standards for service delivery

79. StandardsforallaspectsofanuclearcardiologyservicearepublishedandlinksareavailableontheBNCSwebsitewww.bncs.org.uk.

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Service Delivery in Cardiac Imaging

Basic levels of service for Cardiac Imaging

80. Cardiac imaging departments have a responsibility to ensure that their practiceachieves the highest possible standards. These standards include clinical care,choice of imagingmodality, quality of images and their interpretation, measuredagainststandardssuchaswaitingtimes,facilitiesandspeedof issueof thereport.Standards of diagnostic accuracy are evolving and data for clear standards areincomplete. Departments should be aware of developments and contribute viaresearch,auditdataandnationaldatareturnstosocietiesasappropriate.

81. Commissioning a World Class Imaging Service isaweb-based tool developed to

supportcommissionersofallimagingservices.Itaimstobringtogetheranumberofvaluableresourcesaboutdiagnosticimaginginoneeasyandconvenientreference

tool which will be useful to those who commission, work in or use any imagingfacility.Toreadmoreandaccessthetoolfollowthelink.http://www.18weeks.nhs.uk/Content.aspx?path=/achieve-andsustain/Diagnostics/Imaging/commissioning-guidance

82. Imaging Service Accreditation Scheme (ISAS) TheRoyalCollegeofRadiologists,in

collaboration with the Society and College of Radiographers have developed anaccreditationschemeforimagingservices.Thiswillhelpimprovequalityandpatientexperienceaswecontinuetofocusonsustainingthe18weekstarget.Thisscheme(ISAS)wasformallylaunchedinJune2009andatthetimeofwriting8servicesareworkingwithUKAS as earlyadopters of the scheme. The scheme opened toall

servicesacrosstheUKonOctober1

st

2009.Allimagingdepartmentsincludingcardiac imagingwillbeencouragedtoseekaccreditationoftheirservicesviaISASseehttp://www.isas-uk.org/default.shtml

83. Relevantnationalandinternationalstandardsforcardiacimagingarealsoavailable

fromTheBritishCardiovascularSociety,RoyalCollegeofRadiology,theEuropeanSociety ofCardiology, theAmericanSocietyofCardiologyandother international,modality specific societies. Forexample theBritishSociety forEchocardiographyhasdevelopedanaccreditationschemeforechocardiographydepartmentsincludingstressechocardiography.Theschemefocusesonthequalityof theserviceandisopentoallechocardiographydepartmentsintheUK.See www.bsecho.org

84. TheRoyalCollegeofRadiologistshavepublishedaGoodPracticeGuideforClinicalRadiologistswhichshouldbefollowedbyallmedicalimagingspecialists.

85. Anydepartment performing cardiac imagingmustensure that equipment is up-to-dateandsafeasdescribedpreviously.Whenappropriate,asstatedinnationalandinternationalguidance,equipmentshouldbeinspectedbyqualifiedmedicalphysicspersonnelforqualitycontrolandtheseprocessesmustbeformallydocumented.

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86. Technical staff acquiring images must be appropriately trained, professionallyregistered,ifappropriateandbeabletoshowevidenceoftrainingwithformalCPDprogrammes.Technicalandmedicalstaffreportingimagesshould

• Have appropriatetraining and evidence shouldbeavailable for this.Examplesmight include: BSE accreditation for echocardiography, Certification Board ofNuclearCardiologyaccreditationfornuclearcardiologyetc.

• CompletetherequiredCPDprogrammesannually.

87. Regularauditsofimagequalityandreportingshouldbeperformedwithcomparisontoanagreed“GoldStandard”,eitherlocalornational.Arecordofalladverseeventsshould be kept in the department. Such adverse events should be within theinternationallyacceptedrates.

88. Adepartmentshouldacquiresufficientstudiestomaintainpractice.Reportersand

techniciansshouldperformsufficientscanstomaintainskillsandthiswillvaryfrom

technique to technique. Guidance is available from national societies. This maymean that it is appropriate for local service provision not to offer all imagingmodalities and to focus local expertise into specific imaging services. Traineesshouldworkundersupervisionandtoalevelappropriatetotheirleveloftrainingandexpertise.

89. Every imaging department must ensure that there are systems in place to justify

each imaging examination particularly where ionising radiation is involved. TheIonisingRadiation(MedicalExposure)Regulations2000arebasedonlocal,nationalor international guidelines and ensure that the appropriate available imagingmodality isused. Departments shouldalso ensure the appropriate application of

health andsafety guidance including theapplication of the "as low as reasonablypractical"(ALARP)principleforionizingradiation.

90. All cardiac imagingdepartments shoulddevelopclearly definedqualityassurance

systemswithestablisheddelegatedresponsibilityandclearlinesofcommunication.Cardiac imaging departments should strive for the highest possible levels ofdiagnostic accuracy. Although such standards are limited and often based onliterature studies under optimum conditions of equipment, staffing and technicalability, imaging physicians should remain informed of the available literature andstrive toachieve standards of accuracy similar to the best that is reported in theliteratureunlessagreedminimumstandardsbecomeavailable.

Safety and Clinical Audit

91. Selecting theappropriate test, achieving anappropriateoutcome and interpretingandtakingappropriateactionontheresultofthetestisessential.

92. Cardiac imagingdepartmentsshouldparticipateinappropriateauditprocesses.Alocalauditleadshouldbeappointedandauditshouldlinkinwithtrustwide,nationalandinternationalaudit,asrelevant,withregularmeetingsthroughtheyear.Cardiacimagingteamsshouldworktomonitorandmaintainqualityofthecaretheyprovide,

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recording data honestly and, where necessary, responding to audit results toimprovepractice,forexamplebyundertakingfurthertraining.Theseauditsshouldbeperformed,normallywithcomparisontoa“GoldStandard”.Thenationalsocietiesmay recommend specific audit topics to be addressed for example The Royal

CollegeofRadiologists(RCR)publishedClinicalAuditinRadiology:100+Recipes .(1996). This described how to undertake audit in a systematic and logical way,repeating the cycle and above all choosing audits which are relevant. Thispublicationhasbeensupersededbyanonlineaudittool-‘AuditLive’.

http://www.rcr.ac.uk/audittemplate.aspx?PageID=1016 93. Non-invasivecardiacimagingcarriesrisksanditiseveryoneinthemultidisciplinary

team’s responsibility to manage risk within the department. The followingrecommendationsaremade:

• A recordof alladverseeventsshouldbe keptinthedepartment.Suchadverse

eventsneedtobewithintheinternationallyacceptedrates• Ionisingradiationuseshouldadheretotheprincipleof"aslowasreasonably practical" (ALARP). Radionucletides should be handled according to all appropriate national guidelines. This is particularly important where additional ionising radiation is used beyond theminimum for the core test requirements, (e.g. gated SPECT, CT delayed enhancement or function). In these circumstancestherisksandbenefitsofadditionalinformationshouldbeexplicitly justifiedatdepartmentpolicylevelandforindividualpatients.

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Reporting of Cardiac Imaging

94. In linewithall imagingmodalities it is essential that turnaround times from imageacquisition to issue of report is as prompt as possible, in order for the report to

contributeeffectivelyto thediagnosisandmanagementof thepatient. Toachievethis cardiology and imaging departments should ensure that reporting, typing,verification, and report issue processes are streamlined. There arerecommendationstosuggestminimumstandardsfortheissueofreports,dependentonclinicalurgency.

Urgentcases-Immediate(within30minutes)InpatientsandA&E-SameworkingdayAllothercases-Bynextworkingday.

RadiologyReportingTimesBestPracticeGuidance ,NationalImagingBoardSept2008.

http://www.18weeks.nhs.uk/Asset.ashx?path=/Imaging/RadiologyReportingTimes_September2008_160908.pdf

95. Forsomecardiacimaginginvestigationsjointreportingisbeneficial.Thisutilises

the imaging and technical expertise of both radiologists and the clinicalsubspecialty knowledge of cardiologists, ensuring optimum clinical decisionmaking.All medical staff undertaking reporting of cardiac imaging should beregisteredontheGMCspecialistregisterfortheirappropriatespecialtyandbeabletodemonstratethattheyhadundertakentheappropriatetrainingwithinthecardiacimagingmodality,

96. Consultants in charge of a service may delegate reporting of some cardiacimaging investigations, to other UK registered healthcare professionals,undertaking imageacquisitionand reportingwithin their professional scopeofpractice. Theymust have successfully completed anappropriately accreditedcourse and have maintained their continuing professional development inaccordancewithprofessionalguidelines.Somecardiacimaginginvestigationsaredependentontheskillsoftheoperatorintermsoftheimagesacquired.Forthese investigations the report should be generated by the professionalresponsibleforacquisitionoftheimages.Itmaybeappropriatefortheseimagesto be reviewed and authorised by a supervising clinician registered on theappropriate GMC specialist register or other suitably registered healthcareprofessional,whocandemonstrateanappropriatelevelofcompetencetodoso.

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Financing the Service

97. TheNHShasaresponsibility toprovideappropriatecardiacimaging.Thebenefits

to thepatientofagood cardiacservice intermsofthethreemaincomponentsofqualityasstatedin‘TheNextStageReview–HighQualityCareforAll’ [1],patientsafety,experienceandoutcomes,areclearanditisalsoappropriatetoconsiderthevarious cardiac imaging modalities in terms of the QIPP (Quality, Innovation,ProductivityandPrevention)agenda.

98. ThePaymentbyResults2010-11roadtesttariffsandguidancenoteswhichinclude

thediagnosticimagingtariffsareontheDepartmentofHealthwebsite.Thesenon-mandatorytariffsarefordirectaccessdiagnosticimagingfor2010/11butareusefulforcostingpatientcarepathwaysmorebroadly.http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAn

dGuidance/DH_11010699. Accurate cardiac specific tariffs which relate to the true cost of providing the

procedure for all cardiac imaging modalities would support the development ofeffectivecardiacimagingservices.

100.A combinationof accurate datahandlingand costing will facilitate full funding of

cardiac imagingservicesandallowservices tobeimproved.Trustsshouldensurethat ITstructureswithinallcardiac imagingdepartments aresufficient toallow foraccurate recording of the volume and mix of activity and to allow for audit ofoutcomes.

101.There isaPbRdevelopment site looking specifically at tariffsforcardiacCTandcardiacMRI.Workbythespecialistsocietiesisalsounderwaytosupportaccuratetariff development. NHS Connecting for Health have been asked for some newOPCS(procedure&intervention)codesspecificallyforcardiacimagingtoensureallcardiacworkcanbeaccuratelycoded.

102.ThereisongoingdevelopmentworkbythePbRteamatDHinconjunctionwiththe

British Society of Cardiovascular Magnetic Resonance (BSCMR) on coding andclassificationofthisactivity.UntilthisworkiscompletedthisisexcludedfromPbRtariffs.

103.2010-11 may see a change of direction brought about by tougher economic

circumstances.New features in PbR include the introduction of tariffsset, not onaverage costs,buton thecostofdeliveringbestpractice and also business ruleswhich include the use of marginal rates for increases (but not decreases) inemergencyactivity.

104.TheDraftPaymentbyResultsGuidance for2010-11usefully forcardiacimaging

alsostatesthat

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•Whereaspecialistprovidercandemonstratethatitcarriesoutmorecomplexandcostly diagnostic tests than the average (for example cardiac MRI or CT),commissioners should consider if there is a case for paying more than themandatorytariffsforoutpatientattendances.

•SinglePhotonEmission Computed Tomography (SPECT) scans areexcludedfromPbRin2010-11astheyhaveonlyhaddedicatedcodescreatedforthemintheOPCScodingclassificationin2009-10andasaresulttheunderlyingreferencecostsdonotreflectthistypeofscan.

•A new, unbundled Healthcare Resource Group (HRG) for simpleechocardiogramsreplaces thecoreHRGofEA45Zusedin2009-10.Aswithotherimaging,wehaverebundledthecostsofthisactivity,exceptfordirectaccess.ThereisalsoamandatoryHRGforcomplexechocardiograms(EA45Z).

105.OptionsfortheFutureofPaymentbyResults:2008/09to2010/11isaconsultation

document which states that where secondary care clinicians are making the

decisions on interventions, the proposal is to expand the use of casemix-basedfundingandtounbundleonlyhigh-cost,low-volumeitems.

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Choice of Test

106.Thechoiceofcardiacinvestigation isnotalwaysaclearchoicebetweenimaging

modalities.Theimportantdeterminantsofwhichtestischosenare:

decidingonthequestion(s)tobeanswered consideringwhichoftheavailabletestscouldanswerthequestion(s) knowingthestrengthsandweaknessof theavailable tests (whichmayinclude

knowingwhowilldothetestinsomeoperator-dependenttests) availability,costandconvenience theionisingradiationburdenandanyotherrisktothepatient.107.A well thought-out evidenced imaging strategy may reduce the need for

inappropriate imaging and revascularisation procedures leading to more targeteduseofresourcesforpatientsandbetteroutcomes.

108.The tablebelowgivescomparisonsbetweenthedifferentmodalities.Thistable is

verysimpleandincludeseachmodalityasabroadcategory.Itisnotintendedtobedefinitive information but has been designed particularly to help commissioners,servicemanagers and others less familiarwith theclinical serviceunderstandthedifferentcardiacdiagnosticmodalities.

109.The Medical Exposures Directive [IR(ME)R 2000] requires that all medical

exposurestoionisingradiationmustbejustifiedpriortotheexposurebeingmade.Justification should be based on knowledge of the risks and potential benefitsassociatedwiththeexposure.UsefulInformationaboutradiationdosefromcardiac

imaginginvestigationsandsourcesoffurtherinformationcanbefoundatAppendixB.Imaging for coronary artery disease:

110.The choice of imaging in coronary artery disease is difficult and many of the

currently available imaging modalities are evolving rapidly. These tests can beroughly divided into ‘structural’ such as invasive coronary angiography or CTA(showingtheshapeofthearteriesandthechambersoftheheart,butnotnecessarilyallowingtheimpactofanynarrowinginthearteriestobeassessed)and‘functional’where the objective is to demonstrate how perfusion or contraction of themyocardiumisalteredbystress(see‘demonstrationofischaemia’below)

111.Thedecisionastowhichtousewilldependon localavailabilityandexpertisebut

alsoon the pre-test probabilityof finding that the patienthas significant coronaryartery disease. Pre-test probability is decidedby clinical history, examinationandevaluationofriskfactors.

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Table Comparing Imaging Parameters For Each Cardiac Imaging Modality

Echocardiography Nuclear CMR Angiography CTAngiography

Ventricularfunction +++ ++ +++ ++ ++

Valvefunction +++ + ++ ++ +

Valvemorphology +++ - ++ + +

Coronaryanatomy - - - +++ +++

Ischaemia +++ +++ +++ + -

Blood flow in thecardiacchambers

+++ + ++ ++ -

Costofbasictest

Cheapest=+Mostexpensive=+++

+ ++ +++ +++ ++

Timeforbasictest + +++ ++ +++ +

Reportingtime

Shortest=+Longest=++

+ + ++ + ++

DedicatedequipmentY/N

Y N N Y N

AncillaryequipmentneededY/N

N N Y Y Y

Key -=testnotuseful +to++++++=increasinglevelofusediagnosticallyY=YesN=No

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112.The following cases demonstrate the use of cardiac imaging in a selection ofcommonclinicalscenarios.Cases1-6describefunctionaltestsandcase7anoninvasiveanatomicaltest.

Detection of ischaemia (functional tests)113.Detection of ischaemia in patients with coronary artery disease presents a

challengebecause ischaemia isnotpresent instablepatientsat rest. Instead, theischaemiahastobeinducedorprovokedbystressingtheheart.Stressimagesarethen compared with resting images to detect, quantify and localise ischaemicchanges.Inducedischaemiacanbedetectedwithmyocardialperfusionscintigraphy,withstressechocardiographyandwithstressCMR.Documentationofischaemiaisan important part of the assessment of the patient with coronary disease as thepotential benefit of revascularisation is closely linked to the volume of ischaemicmyocardium.Thefollowingclinicalcasesdescribehowstressimagingcanbeused

todecidewheninvasiveinvestigation(i.e.coronaryangiography)andinterventionaltreatment (including Percutaneous Coronary Intervention and Coronary ArteryBypassGraft)may,ormaynot,berequired.

Case 1

114.A 63 year old man presented with stable angina occurring when walking about100montheflat.Hissymptomswerenotadequatelyrelievedbymedical therapy.Myocardial PerfusionScintigraphy (MPS) showed an exercise inducible perfusionabnormalityintheLADterritory(arrowed)butnormalperfusionelsewhere.Invasivecoronary angiography showeddisease in both the left anterior descending (LAD)arteryandthecircumflexartery.InsertionofastentacrossanarrowingintheLADalone(leavingthecircumflexlesionbecauseitwasnotcausingischaemia)abolishedhissymptomsofangina.

Case 2

115.A58yearoldwomanpresentedwithatypicalchestdiscomfort.ExerciseECGwasinconclusive. CT coronary angiography showed some coronary atheroma (left,arrowed)butMPSwasnormal(the imagesshownarestresscentre,rest right,all

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areas ofmyocardiumwith tracer uptake>70% inorange). Thecoronary diseasewasthereforenothaemodynamicallysignificantandthesymptomswerenotangina.No invasive coronary angiography or revascularisation treatment was indicated.Secondary prevention therapy was initiated because of risk factors and the

demonstrationofearlycoronarydisease.

Case 3

116.A66yroldmalepresentedwithbreathlessnessandstableanginaonexercise.Hehad recently suffered amyocardial infarctionwhilst abroad. Invasive angiographyhadshownthattheleftanteriordescendingcoronaryartery(LAD)wasoccludedandthattheanteriorwalloftheheart(suppliedbytheLAD)wasnotcontractingnormally. A CMR studywas requested to determine if therewas any evidence of residualischaemia in the LAD territory and to see also if there was viable myocardium.DuringadenosinestressCMRtherewasclearevidenceofalargeareaofinducibleischaemia intheanteriorwallandseptum(Figure1A,arrows)andwithonlyaverysmallareaofirreversiblesubendocardialinfarction(Figure1B,arrow),i.e.theheartmuscle was almost all viable but most of the muscle supplied by the LAD washibernating(notcontractingbecauseofchronicsevereischaemia).ThepatienthadPCIandstentingtotheLADocclusionandhissymptomsresolvedcompletely.Notethatinthiscaserevascularisationhadthepotentialtoimprovenotonlyhissymptomof angina but also his left ventricular function which is related to his long termprognosis.

1A) 1B)

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Case 4

117.A62yroldmalepresentedwithstableanginaonexercise.TherewasahistoryofMIoneyearpreviously.InvasiveangiographyhadshownthattheLADwasoccluded.ACMRstudywasrequestedtolookforevidenceofischaemiaorviabilityintheLADterritory.During adenosine stressCMR there was extensive hypoperfusion in theanteriorwallandseptum(Figure2A)whichcorrespondedalmost identically to theareaof transmural infarction (whitearea,Figure2B).TheCMRdemonstrated thatrevascularisation of the LAD territory, either by PCI or CABG, was unlikely toimprove the patient’s symptomsbecause the heartmuscle in that areawas non-viablefollowinghisinfarct.

2A) 2B)

Case 5

118.A72yearoldwomanpresented3weeksafteranepisodeofprolongedcardiactype

chestpain.ECGshowedevidenceofacompletedanteriormyocardialinfarction.AninvasivecoronaryangiogramshowedaneartotalocclusionoftheLAD.Theclinicalquestionwasasked ifopeningof the LADand insertion of astentwas indicated.DobutamineStressEchocardiogramwith contrast showedanapical infarctat rest(whitearrows)thatdidnotchangewithstress(dashedwhitearrows)suggestingthatthe muscle tissue subtended by the LAD was not viable. Consequently norevascularisationwasperformedandmedicaltreatmentwasrecommended.

RESTREST

STRESSSTRESS

Case 6

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119.A72yearoldmanpresentedwithworseninganginadespiteadequateanti-anginal

treatment.ADobutamineStressEchowithcontrastdemonstrated ischaemia intheLADterritorywithnormalthickeningoftheantero-septumatrest(whitearrows)and

reducedthickeningatstress(dashedarrows).Invasivecoronaryangiogramshowedatightnarrowinginadiagonalvessel.Stentinsertionacrossthenarrowingabolishedhissymptomsofangina.

RESTREST

STRESSSTRESS

120.Theseclinicalexamplesdemonstratehowfunctionalstressimagingcanbeusedto

identify thosepatients withstable coronary artery diseasewho aremost likely tobenefitfrominvasivecoronaryangiographyandsubsequentrevascularisation.Justas importantly, they can identify patients who are unlikely to benefit fromangiographyandrevascularisation.

121.Atpresent,thereislittleevidenceaboutwhichfunctionaltestismostcost-effective.

Theconceptofaone-stop-shopwithasingleimagingtechniquethatcanhandleallproblems is currently not realistic. Local services need to develop skills and anequipmentbasetoprovidethebreadthofcardiacimagingrequiredtoprovideahighqualityserviceforcardiacpatients.

Non invasive anatomical tests

122.Anatomical imagingdemonstrates thedistributionand severityof coronaryarterydiseasetoplanfortreatment.Itisalsoimportantintheexclusionofcoronaryarterydiseaseandcandetectvesselnarrowingatanearlierstagethanfunctionalimaging.

CTangiographycanalsodetectdiseaseinthevesselwall

Case 7

123.A 47 year old female presents with symptoms suggestive of angina and anequivocalexercise test.CardiacCTangiographywasperformedusingprospectivegatingand low kV techniques.This generateda total dose for the examination ofonly0.4mSv(DLPof28,usingchestconversionfactorof0.014).Thescantook25

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seconds and showed no evidence of coronary disease (either atheroma ornarrowing).Shewasdischargedfromhospitalfollow-updirectfromthescannerwithnoneedtotakeanyfurthermedication.

Theimagesdemonstratenormalcoronaryarteries.

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Cardiac Imaging in Specific Clinical Pathways

Cardiac Imaging in patients with recent onset chest pain.

124.OneofcornerstonesoftheNationalServiceFrameworkforCardiology,publishedin2000,wastheestablishmentof“RapidAccessChestPainClinics”designedtoseepatients with recent onset chest pain. At the Rapid Access clinic, the patient isassessedclinically,hasarestingECGand,ifappropriate,anexerciseECG.

125.ThepublicationofNICEGuidanceon“Chestpainofrecentonset:assessmentand

diagnosisofrecentonsetchestpainanddiscomfortofsuspectedcardiacorigin”willchangehow these patients are managed andwill shift the standard investigationfromexerciseECGtestingtocardiacimaging.TheexerciseECGwillnolongerberecommended to diagnose or exclude stable angina in patients without knowncoronary artery disease. Instead, the likelihood of coronary artery disease will be

estimatedfromatabletakingintoaccount theclinicalassessmentand the12-leadECG.Furtherdiagnostictestingwillthenberecommendedasfollows:

•IftheestimatedlikelihoodofCADis61-90%,offerinvasivecoronaryangiographyasthefirst-lineinvestigationifappropriate

•IftheestimatedlikelihoodofCADis30-60%,offerfunctionalimagingasthefirst-

linediagnosticinvestigation

•IftheestimatedlikelihoodofCADis10-29%,offerCTcalciumscoringasthefirst-

linediagnosticinvestigation

126.MosthospitalsandcardiacnetworksintheUKhavesufficientcapacityforcoronary

angiographyforthoseathigherrisk.However,implementationofthisNICEguidelinewillresultinasignificantlyincreasedrequirementforfunctionalimaging(inplaceofexercise ECG testing) and, formany centres, the need for of a new cardiacCTservice.

Cardiac Imaging in patients with chronic stable angina

127.Coronaryangiographyhasbeenregardedasthegoldstandardinvestigationforthe

diagnosisofcoronaryarterydiseaseformorethanfortyyears.Inpatientspresentingacutelywith STsegmentelevationmyocardial infarction,or in patients presenting

withnon-STelevationMIwithdynamicECGchangesandraisedbiochemicalcardiacmarkerstheevidenceforsignificantmyocardialischaemiaisoftenalreadyavailable,so functional imaging is unnecessary. Hence revascularisation procedures areusuallycarriedoutbasedontheangiographicfindingswithoutfunctionalimaging.

128.In patients withmore stable symptoms (i.e. not covered by the NICE guidance

describedabove),anumberofrecentdevelopmentshavecastdoubtonthepremise

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thatpatientswithsuspectedcoronarydiseaseshouldhavecoronaryangiographyasafirstlinetesttoconfirmorrefutethediagnosisofcoronarydisease.

129.Itislikely,therefore,thatmorewidespreaduseoffunctionalcardiacimagingpriorto

angiography could help to detect those patients most likely to benefit fromrevascularisation.Thosepatientswithabnormalfunctionalimagingwouldstillrequirecoronaryangiographybutitmaybepossibletoreducetherequirementforcoronaryangiographyinthosepatientswhohavenormalcoronaryvesselsormild/moderatecoronarydiseasewithnoevidenceofreversibleischaemiabecausetheycansafelybemanagedmedicallyinthefirstinstance,withcoronaryangiographybeingusediftheirsymptomscannotbecontrolled.

How many patients might this affect?

130.Accordingtothe2008-9HospitalEpisodeStatisticsdataforEngland,thefiguresfor

diagnosticcoronaryangiographyandrevascularisationonstablepatients admittedfromawaitinglistwereasfollows:Coronaryangiography

CodesK63.1–K63.9

119,954

PCI

Codes K49.1 – K50.9 andcodesK75.1–K75.9

30,727

CABG

CodesK40.1-K45.9

18,232

131.These data suggest approximately 71,000 stable patients underwent diagnostic

coronaryangiographybutdidnotproceedtorevascularisationviaPCIorCABGinEngland.132.What is not clear is the proportion of these patients who had some form of

functionalimagingprior toangiography.However, it is likely thatahighproportionwerereferred fordiagnosticcoronaryangiographywithoutprior functionalimaging.Insomecardiacnetworks, ithasbeenacknowledged that patientswith suspectedstableanginaarereferred forcoronaryangiography ratherthan functional imagingsimplybecauseofeaseofaccess(i.e.shorterwaitingtimesforangiographythanfornon-invasivefunctionalimaging).

133.Apilot study intheGreaterManchesterandCheshireCardiovascularandStroke

Networkiscurrentlyexaminingthisissue(SeeAppendixC,page47).Estimatesaregivenofthelikelybenefitstopatientsofsuchanimagingstrategytogetherwiththepossiblebenefitstocommissionersintermsofareducedrequirementfordiagnosticangiographyandappropriateselectionofpatientsforrevascularisation.

Imaging for valvular disease:

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134.Theimportantquestionsinvalvediseaseare:

• Whichvalve(s)ismalfunctioning?

• Howbadlyisitmalfunctioning?

• Whatistheeffectontherestoftheheart?• Why is the valve malfunctioning and what is the structure of the valve and

surroundingareas?

• Isthevalveinfected?135.Echocardiography has revolutionised the assessment andmanagement of valve

disease.Itprovidesgoodstructuralinformation(particularlywithTOEand3-D)aboutthevalveand itssupportingstructures,and,withDoppler, good informationabouttheseverityofthelesionandwhetherthevalveisrepairable.Itcanalsoassesstheimpactofthevalvelesion(s)ontheheartasawhole.Echoisthemainstayofvalvefollow-up, being easily repeatable and safe. Patients can bemanaged for many

yearswithregularechoassessments.136.CMRisdevelopingasatoolforvalveassessment.Itcanprovidegoodinformation

about changes in ventricular size and shape and some information about valvestructure.

137.Cardiac Catheterisation is used for patients with valve disease in whom non-

invasivetestssuggestthatvalvesurgerymaybenecessary.Directmeasurementofintracardiac and intrapulmonarypressures canverify non-invasive haemodynamicassessments. Imagingof thecardiacchambersand aorta gives informationaboutleaking valves and left ventricular function. The coronary anatomy can also be

visualisedtoensurethatanyimportantcoronarydiseaseisdiscoveredbeforevalvesurgery.

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Conclusions

138.Moderncardiologyservicesneedaccesstothetechniquesdescribedinthisreport.

139.Therearefewcomparativedata toallowselectionof techniquewhencapabilities

overlap,forexampletheestablishedtechniquesofmyocardialperfusionscintigraphyand stress echo must not be cast aside because of the emergence of newtechnologies.Untilwehavecomparativeevidence,localfacilitiesandinterestwillbethemajorfactorindeterminingtheshapeoflocalprovision.

140.Incentreswithoutaccesstofunctionalimagingofanysort,thedecisionwhethertoestablishmyocardialperfusionscintigraphy, stressecho,orcardiacMRshouldbedeterminedbylocalfactorssuchastheavailabilityofsupportfromalocalcentreofexcellence,andthetrainingpotentialandenthusiasmoflocalmedicalandtechnical

staff.Equipmentandrunningcostsareclearlyimportantissuescomplicatedbythefactthatsomeequipmentcanonlybeusedforonesortoftest,whereasothershaveusedoutsidecardiology.

141.When planning cardiac imagingservices,commissionersandtheteamdelivering

theseservicesshouldbeawareofthecomplexissuesdescribedinthisreport.Inparticularthetechnologyinvolvedinallmodalitiesforcardiacimagingisevolvingatarapidpaceanduptodateknowledgeisessentialforservicemanagement.

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AppendixA

Equipment Specification

Coronary AngiographyCoronary angiography requires a specialised laboratory with appropriate radiationprotection. Most catheterisation laboratories arededicated tocardiacproceduresbutsomearejointwithotherinterventionalradiologyservices.Catheterisationlaboratoriesshouldhavethecapabilityfordigitalacquisitionandstorageofimagesconnectedtoadigitalarchive.Fullresuscitationequipmentmustbeimmediatelyavailable.

MinimumEquipmentSpecification

• Highfrequencyx-raygeneratorwithpowerratingofatleast50kWpertube.

• User-selectablekV/mAcurvesforfluoroscopyanddigitalacquisition

• Automaticskinsparingfilterselection

•

Selectionoffluoroscopyanddigitalacquisitionpulseratesbetween7.5and30framespersecond.

• LastImageHold

• FluoroStoreandGrab

• SourcetoImageDistance(SID)Tracking

• Temporarystoredautopositioning

• VirtualCollimationandvirtualcontourfilterpositioning.

• Easeofaccesstopatientwheninuseandinemergencies

• TabletosupportCPRwhenatfullextension

• Sufficienttabletraveltoimagehearttoupperfemoralarteries

• Flatpaneldigitaldetectorwithlimitingresolution>2.5lp/mm

• Atleasttwomagnifiedfieldsofview• PACS/RISintegration

• DoseAreaProduct(DAP)andskindosedisplayedinroom

• Displayofphysiologicaldataalongsideimagingdata

• Rotationalangiographyisdesirable Cardiac CT. ApartfromatveryspecialistcardiaccentresaCTscanneris likelytobeusedfora fullrangeofexaminationsofthebody.Thefollowingspecificationisforthecardiacelementonly.Technology in this area ischanging rapidly andmanynew features areprovingvaluable inproducingreliablehighqualityimagesatreduceddoses.Thisspecification

should thereforeberegardedas theminimumstandard fornewCTpurchasesat thetimeofpublicationonly.

Theminimumrequirementforcardiaccomputedtomographyangiography(CCTA)isa64slicemulti-slicescannerwiththeassociatedcardiachardware&software.Thenon-diagnosticrateofscannerswithlessthanthishasbeenshowntobeupto10%greaterthanthosewith64slices.Whilsttherearededicatedcardiacscannerswitheitherhighertemporalorspatialresolution,orcoverage, theincrementalbenefitof suchequipment

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(withitsaddedcosts)hasyettobeprovenincomparativetrials.Theadditionalcostsofsuch technology are therefore at the discretion of the purchasers. The provision ofprospectivegating,shouldhowever,bemandatory,as thishasbeenshownto reducethe radiation dose in selected patients by up to 75%. Whilst the position of theCT

scanner will be dictated by local circumstance ideally access from the traumadepartment and the coronary care unit should be considered because of CCTA’semergingroleinacutecardiacconditionsContrastinjectorstobeutilisedinCCTAshouldbeabletodeliverupto7.5ml/secandbe dual headed as the use of a saline “chaser” reduces contrast requirements andfacilitatesthedetectionofintra&extracardiacshunts. Asthesupervisingconsultantwillneedtoreviewthecasefortechnicalsuccessthereisa requirement foranappropriateworkstation(withcardiacsoftware)withinthecontrolroomofthescanner.Theneedforfurtherworkstationswillbedecidedbylocalworking

practices, but generally at least one other is required because of the need for casereviewwithclinicians.Minimumequipmentspecification:

• 64simultaneousslicesperrotation

• 20mmZ-axiscoverageperrotationattheisocentre

• ProspectiveECGgatingandprospectivelyECGtriggeredscan(axialscan)

• RetrospectiveECGgating

• ECGcontrolledcurrentmodulation(helicalmode)

• Minimumpitchof0.2forcardiacscanning

• Temporalresolutionofatleast200mSforasinglesector

• Scanplaneresolutionofatleast12.5lp/cm@10%MTFresolution• Z-axisresolutionofatleast8lp/cm@10%MTF

• ECGediting

• Contrastmediabolustracking

• Dualheadedcontrastmediainjector(maybesuppliedseparately)

• ECGmonitorSoftwarepackagestoinclude:

• CTAngiography

• CoronaryVesselAnalysis

• Cardiacfunction&analysis

•

Cardiaccalciumscoring Cardiac Ultrasound and Stress Echocardiography

Thereisarangeofequipmentwithwhichtoperformcardiacscanning.Unitsthatarespeciallyoptimised forcardiologyandgeneralpurposesystemswhicharesuitableforcardiologywiththeuseofspecialisedprobes(suchasphasedarraysectorandtrans-oesophageal transducers). The working lifetime of an ultrasoundmachine is usuallytaken to be tenyearshowever itis likely to needamajorupgradeatleasteveryfive

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years.Thelifetimeofanultrasoundprobeisusuallyshorter,andtypicallyaprobewilllastforaboutfiveyearswithcarefuluse.

• Ability todisplayB-modeimagesanddopplerspectrumssimultaneously in real

timeknownas‘duplex’operation.• Secondharmonicimaging

• Colourmapping

• Pulseddoppler,steerableandstand-alonecontinuouswavedoppler.

• 30framespersecondatadepthof12cmwithoutlateralresolutionloss.

• Ideallytissuedopplershouldalsobeavailable.

Equipmentforstressechocardiographyrequiresanechocardiographymachinecapableof digital image acquisition and storage. Most current machines are available withspecific software including harmonic imaging for transpulmonary contrast. Mostdepartments performing high volume stress echocardiography use transpulmonary

contrastinahighproportionoftheirstudies.Thedevelopmentofharmonicimagingandtheuseoftranspulmonarycontrastagentstoopacifytheleftventriclemeansthatfewpatientsareexcludedduetoinadequateimagequality.Thissoftwareenablesthedigitalcaptureandsimultaneousdisplayofimagesrecordedatdifferentstagesofthestressprotocol.Minimumequipmentstandards

• Echocardiography machine with stress specific software, including harmonicimaging.

• Digitalimagecaptureandsimultaneousdisplayofmultiplecineloops.

• Digitalarchivingforfuturereview.

• Variablerateelectronicpumpforpharmacologicalstressagents.• Dedicatedpumpforinfusionoftranspulmonarycontrast.

Cardiac MR (CMR)

Definingminimum equipment standards inCMR is difficult: the attainment of certainhardwarehigh-endspecificationsfacilities(e.g.ahighnumberofRFReceiverchannels)maynotbeadvantageousifothercomponentsoftheCMRlimittheabilityofthesystemtousefullyexploitthese. Anynew installationofaclosedbore1.5or3TCMRscannercanbecardiacenabled.Withexistingequipment, thepreferredalternativeapproachwouldbe toensurethata

standard includes reasonable specifications for theacquisitionpulse sequences,e.g.numberofslicesinaperfusionsequence/heartbeatratherthanphysicalhardwarelimitsperse.

The following suggestions forminimum standards for CardiacMR are subject to theabovecaveats:

• Afullymaintained,sharedordedicatedMRIscannerwithcardiaccapability

• Sufficientmagnetaccesstoachieveminimumannualunitnumbers

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• Proceduresinplacetoensureasafeenvironmentandquality.-

• ECGgating,patientmonitoring(includingbloodpressureandoxygensaturation)

ForanewCMRinstallation,BSCMRrecommendationsare:

• RFsubsystem:16RFchannels • Gradientspecifications:30mT/m,150mT/m/msec

• ArtefactresistantECGhardware/software(e.g.vectorcardiogram)

• Torso/Body/Cardiacrfreceiverarraywith>5channels

Specific cardiac sequences

Theminimumis:

• SSFPcineimaging(bFFE,FIESTAorTrueFISP)

• BlackbloodT1/T2WTSEsequenceswith/withoutfatsat

• Flow/velocitysequences

• Largevesselangiography

• LategadoliniumenhancementimagingRecommendedis

• Realtimecinesequence

• Perfusionsequences

• Alternativelateenhancementsequences(3D,PSIR,IR_SSFP)

• 3Dwholeheart

• Othersequences(STIR,tagging,coronarysequence,cardiaciron)

Specialist software for analysis

Theminimumis:

•

VolumetricquantificationofLV/RVvolumesandmass• Quantificationofvelocityandflow

• 3Dangiographicreconstructionwithrespiratorycompensation Additionalsoftwaremayinclude:

• complex3Dangiographicreconstruction,

• perfusionquantification,lateenhancementquantification,

• LVanalysiswithlongaxisfunction,tagginganalysis.

Other equipment

• Resuscitationfacilities(includingdefibrillation/Oxygen/suction),

• AnemergencytrolleywithspecificdrugstodealwithpotentialreactionstoIV

contrastmediaandstressors. • MRsafewheelchair&trolley.

• Monitoringequipment

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Gamma Camera for Nuclear Cardiology

Apartfromatveryspecialistcardiaccentresagammacameraislikelytobeusedforarangeofexaminationswithinthebody.Thefollowingspecificationisforthecardiacelementonly.

• GeneralpurposeSPECTgammacamera

• Largefieldofview

• Abilitytoselectenergywindowandcollimationappropriatetotheradionuclideandtracer.

• Atleasttwodetectorsoperableinasuitableconfigurationsee(1)below.

• Lowenergygeneralpurpose(LEGP)collimatorisrequiredforusewith201-Thalliumtracers(2)

• Lowenergyhighresolution(LEHR)collimatorfor99m-Technetium

• Facilitytoreviewimagedataelectronicallyusingacontinuouscolourscale

• FacilitytoreviewECG-gateddatatoverifysuitablegating

Dualdetectorsystemsshouldusethedetectorsina90ºconfigurationanda180ºorbitfrom45ºrightanteriorobliqueto45ºleftposterioroblique.Triple-detectorsystemsshouldusea360ºorbit.Optimalchoiceisdependentupontherelativedesignspecificationsofthespecificcameramanufacturer’sLEGPandLEHRcollimators

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Appendix B

Cardiac Imaging: Approximate Doses

No radiation dose

Ultrasound (Echo Stress Echo)usessoundwavesandnotionizingradiation MRIismagneticresonanceanddoesnotapplyionizingradiation,

Radiation Dose

Nuclear Medicine:Source:HartandWall2003/04NuclearMedicine

Procedure Radioisotope Effectivedose(mSv)Cardiacbloodpool 99Tcm 4.7

201Tl 12.9Myocardium99Tcm 3.1–3.7

Angiography

Source:Hartetal.2005andHartandWallNRPB-W4foreffectivedoseMedicalExaminationsonAdultsProcedure Meandosearea

product(Gycm2)ThirdQuartiledoseareaproduct(Gy

cm2)

Effectivedose(mSv)

Coronary Angiography

25.7 29.0 6.6

Angiographyofcoronarybypassgraft

42.3 Toolowstatistics Toolowstatistics

CT Angiography

Source:InternationalAtomicEnergyAgencyhttp://rpop.iaea.org/RPOP/RPoP/Content/Documents/TrainingCardiology/Lectures/CAR

D_L11_CardiacCT_WEB.ppt#267,13,TypicalEffectiveDoseValuesforCTCardiacCT–radiationdoses,dosemanagementandpracticalissuesLecture11Page11:TypicalEffectiveDoseValuesforCT:Ca-Scoring:1.5–5.0mSvCardiacCTA:10-25mSv

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Page25:EffectivedosesforCardiacImagingProcedures Modality EffectiveDose(mSv)

EBCT 1.0–1.3CaScoring

MDCT 1.5–6.2*EBCT 1.5–2.0*CTAMDCT 6.7*-25.0

CardiacSPECTwTc-99morTl-201 6.0–15.0CA(diagnosticonlywfluoroscopy) 2.1*–6.0ChestX-ray 0.1HunoldP.etal.,Radiology2003ItshouldhoweverbenotedthatCTdosesarechangingrapidlyandnewertechnologyfacilitatesdosereduction

Cardiac Nuclear Medicine

Some‘nuclear’cardiacexaminationsthatarecommonlyusedtogivedifferentclinicalinformationaresummarisedinthetablebelow,withaveragedoserangesforeachtest.Examination Isotope Pharmaceutical Activity

(MBq)

ED (mSv) Time

MUGA

(ventricular

function, EF)

99Tcm Pertechnetate 800 6 1hour

MPI

(Ischaemia, EF)

99Tcm Sestamibi 400-800 4–8(Stress+Rest=8-16)

2dayprotocol

MPI

(Ischaemia, EF)

99Tcm Tetrofosmin 400-800 3-6(Stress+Rest=6-12)

2dayprotocol

MPI

(Ischaemia, EF)

201Tl Tl+ 80 14 1dayprotocol

Tissue viability 18F FDG 400 8(+CTdosefor AC)

2hours

Dosecouldrangefrom3mSvto16mSvdependingupontheinvestigationchosenbasedon70kgpatientswithnormaluptake.

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47

Appendix C

Innovative Practice Examples from the Cardiac Networks

1. Non-InvasiveImagingPathway2. ImprovedQualityStandardsforEchocardiography

3. ImprovedDataCollectionandPlanning

4. ImprovedCardiacDataTransfer

5. PACS/ITCasestudy


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Innovative Practice Examples

1.Non-Invasive Imaging Pathway

Greater Manchester Cheshire Cardiac and Stroke Network pilot a non-invasive

cardiac imaging pathway for patients presenting through the rapid access chest pain

clinic with stable angina.

The Issue

Capital expansions in catheter laboratory facilities across Greater Manchester haveincreased the availability of invasive angiography which has culminated in shorterwaiting times over the last few years. This has resulted in patients who aremoresuitable for non invasive imaging, which has longer waiting times being offered

angiography. All cardiologists across the network have agreed that there are manypatients presenting with stable angina that are appropriate for non invasive imagingbeing referred for angiographydue toeaseof access.This lackofavailabilityofnoninvasive imaging is due to the limited specialist imaging workforce and lack ofcommissioned capacity toprovide themost appropriateandcost effective imaging.Astrategy tosupport the implementationof thestableanginapathwaywhichhasbeenclinicallyendorsedandfullysupportedbypublichealthwillensurethatpatientsremainonthemostappropriateagreedclinicalpathway.(SeeFig.1-Pathway)

The proposed approach

TheagreedpathwayalsoencompassesimplementationoftheAnginaPlan,whichisa

mandatory aspect of the agreed service specification. The Angina Plan is a briefcognitivebehaviouralinterventionforpatientswithstableangina.Theaimistoeducatepatientsto correct cardiac misconceptions and encourage a healthier lifestyle, thusimproving symptoms andqualityof life. It isaprogrammethat can be undertakenbytrainedlayworkers.Ithasbeenshowntoreduceepisodesofangina,GTNuse,anxiety,depression and physical limitation and increase activity in patients with stableangina.An alternative to the AnginaPlan couldbeused but must increase healthierlifestylesandmedicaladherence.Benefits to patients

Angina is a major cause of poor quality of life but many patients are not treated

appropriatelyduetoabouta third ofpatientshaving theiranginamissedonexerciseelectrocardiogram(ECG)andathirdofthosewithoutanginabeingwronglydiagnosedas having angina. This proposal for a major expansion of cardiac imaging wouldimprovethissituationmarkedly.

Patient’sreferraltorapidaccesschestpainclinicwill,iftheyareassessedasmediumorhighrisk,haveimmediateaccess(whichmaybethefollowingday iftheyneedfurtherpreparationbeforethetest)tothemodalitiesofimagingidentifiedinthepathway.Forup


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to 10% of patients Dobutamine Stress Echo (DSE) is not appropriate and they willrequireanalternativemodalityortest.

The wider benefits (Quality and Productivity)FunctionalimagingwillgiveahighersensitivityandspecificitythancontinuingrelianceonexerciseECG.Thecardiologistsandcardiacinvestigatorshaveagreedapathway(Fig.1). If theamountofangiographyand revascularisation remainsunchanged,thenthe cost-effectiveness depends on how long a misdiagnosis is accepted for falsenegativesandfalsepositivesasaresultofexerciseECG.However,itisexpectedthattherewillbeaconsequentialreductioninangiogramsandrevascularisation.

The break even point is when 100 functional imaging investigationsresults in areduction of 10 angiographies, 2 angioplasties and 2 Coronary Artery Bypassprocedures.Althoughthismaynotbefullyachieved,someofthisreductionwillalmost

certainlyoc