The IAEA’s activities on radiation protection in interventional cardiology
International Atomic Energy Agency, Vienna, Austria
Received 11 December 2006; accepted 21 April 2007
The International Atomic Energy Agency (IAEA) under its
mandate of developing and applying standards of radiation safety has initiated
a number of activities in recent years on radiation protection in
interventional cardiology. These activities are implemented through four
mechanisms, namely training, providing information through the website, research
projects and assistance to Member States through Technical Cooperation (TC)
projects. Major international initiatives have been taken in the area of
training where more than half a dozen regional training courses have been
conducted for cardiologists from over 50 countries. Additionally four national
training events for over 300 medical and paramedical staff members involved in
interventional procedures were held. The training material is freely available
on CD from the IAEA. The newly established website provides information on
radiation protection issues . Two coordinated research projects have just
been completed where peak skin doses to patients undergoing high dose
interventional procedures were studied and factors to manage patient doses were
identified. The technical cooperation projects involving protection in cardiac
interventional procedures have 30 countries as participants. © 2007
Biomedical Imaging and Intervention Journal. All rights reserved.
Keywords: Training in radiation protection, cardiac
catheterization- radiation protection, IAEA training, radiation protection in
The number of interventional cardiological procedures
continue to increase at a steep rate in most countries. As a result,
cardiologists employ a significant amount of radiation in most cases that can
be matched only with interventional procedures performed by radiologists. While
interventional radiologists normally undergo training in radiological physics
and radiation protection (RP&RP) during their residency, the same is not
true of cardiologists. In most countries cardiologists have no training in
RP&RP. In previous years, typically in the late 1970’s and early 1980’s
when the interventional era started, radiologists either performed the cardiac
interventional procedures or were associated with the procedures. Over the
years cardiologists have acquired independent catheterization laboratories
(cath labs) but have not been trained in the same way as radiologists. This
creates definite radiological protection problems for patients and for
cardiologists themselves [2,3]. A number of radiation induced skin injuries
have been reported in patients undergoing cardiac angioplasty and other
interventions . When cases of radiation injuries were brought to the courts,
the cardiologist invariably had no knowledge about the possibility of such
injuries, as their training did not cover radiation effects. Further, RP&RP
is hardly taught in medical schools during undergraduate studies. Medical
professionals who undertake further education in radiological specialties such
as diagnostic radiology, nuclear medicine and radiotherapy are taught RP&RP
The International Basic Safety Standards (known as BSS)
for Protection against Ionizing Radiation and for the Safety of Radiation
Sources, published by the International Atomic Energy Agency (IAEA) and jointly
sponsored by FAO, ILO, PAHO and WHO , require that all personnel whose work
has implications on protection and safety be appropriately trained and
qualified so that they understand their responsibilities and perform their
duties with appropriate judgment and according to defined procedure. The BSS
also requires that the training criteria be specified.
Realizing these lacunae in effective training, the IAEA
has initiated actions to create awareness among interventional cardiologists on
risks to patients and staff in fluoroscopic angiographic procedures performed
Recommendations for training have emerged from various
national and international sources [5-10]. Most of these are
recommendations, consensus statements or are derived from general requirements
or Directives . The IAEA has developed a curriculum with educational
objectives specifically for interventional cardiologists (Table 1). A review of
recommendations on training from different sources can be found in a recent
publication by Rehani . It is aimed primarily at developing countries where
cardiology professional societies are not yet sufficiently advanced to
undertake separate modules for basic and advanced curricula in the field of RP.
For such countries, a simple module is ideal, particularly in view of the lack
of experts in RP&RP in diagnostic imaging to teach the subject to
cardiologists. The IAEA has also prepared educational material in the form of
PowerPoint slides on CD entitled ‘IAEA Training Material on Radiation
Protection in Cardiology’. The material is available free of charge and can be
obtained by writing to firstname.lastname@example.org; and will in future be
available for download from the website . Based on this training material, the
IAEA has conducted a large number of training courses (Tables 2 and 3). The
feedback from the participants is given in Table 3. It is quite evident that
training in radiation protection has been inadequate in most countries and the
need for formal training is felt across the board and includes training for
national requirements within a legislative framework. The survey also included
feedback on factors such as length of the course, suitability of the curriculum
and further recommended actions. 92% of the participants in Vienna and 96% in
the Singapore meeting stated that the course length of two days was suitable.
The curriculum was, by and large, satisfactory, only very few participants
mentioned that it was slightly too technical. The almost unanimous opinion was
that such programmes should be conducted more often and in many countries,
papers on RP should be published in cardiology journals and RP lectures should
be included in cardiology conferences.
To consolidate the gains and maintain the momentum
generated by training, the IAEA has initiated a project under a Regional
Cooperation Agreement (RCA) for Asia to create a network of cardiologists who
will continue radiation protection in their countries through the national and
regional cardiological societies. The group of cardiologists trained by the IAEA
would meet every year and develop strategies and action plans. The project
started in 2007 and the first meeting of the network was held in Sarawak, Malaysia, wherein it was decided to start an e-newsletter soon. This will, in all
likelihood, be the very first newsletter by cardiologists in the area of
radiation protection. The network of Asian cardiologists shall organize
sessions on radiation protection in various cardiology conferences in the
How much training is adequate? This issue has been addressed
in a recent publication by the author of this paper . To quote from this
paper “Since the intensity of radiation employed by interventional
cardiologists per patient, and collectively based on workload, is no less than
that employed by interventional radiologists, the training standards of
RP&RP in interventional cardiology should also match those in
interventional radiology. However, this may be practically impossible to
achieve, much as it is desired. Attempts should be made to begin at least with
what is practicable and achievable. This stems from the fact that
interventional cardiology may consist of just 5-20% of the work of many
cardiologists, whereas it may comprise more than 50% of the work of most
interventional radiologists. In view of pressing critical care engagements of
cardiologists, the IAEA decided to introduce a simple programme of two days
duration covering 12-14 hours of training. At the moment, such initiatives are
not mandatory and it is desirable that the professional bodies should move
further ahead in the best interest of the profession and professionals to
implement the guidelines”.
IAEA has recently launched a public website specially
dedicated to radiological protection of patients . The website includes
interventional cardiologists as one of target groups among health
professionals. At the moment the website includes answers to the following
- Are radiation induced skin injuries common among patients undergoing
- What problems are associated with diagnosis of such injuries?
- Can radiation injuries be prevented?
- How high is the exposure in cardiac interventions in comparison to chest
- Which factors can affect patient dose in cardiac interventions?
- How can I manage patient exposure?
- What adverse effects could occur as a result of dose reduction actions?
Staff protection - Some of the measures to reduce
patient dose will also result in a reduction of staff dose
- Is the exposure to the cardiologist much higher than to
- Is there a risk of developing cataracts after several years of work in a
- Can I work my full professional life in a catheterization laboratory and
have no radiation effects?
In future the website will have more information for
patients. The information about training courses is available at the website
Two coordinated research projects have just been
completed, one entitled “Evaluate quantitatively and promote patient dose
reduction approaches in interventional radiology” and another “A Pilot Study
Exploring the Possibility of Establishing Guidance Levels in X ray Directed
Interventional Procedures”. The results of both of these projects are under
publication as TECDOCs of the IAEA and will provide useful material for
Assistance to Member States through technical cooperation (TC) projects.
The IAEA has regional projects in all the four regions of
the world, namely Asia, Europe, Africa and Latin America. Information about
these projects can be found at the website .
More than 30 countries are participating in Task 1, which involves
radiation protection in interventional procedures. Results of these projects
will be available on the above website in the near future
All these combined activities ensure that the IAEA plays a
leading role in the world on radiation protection in cardiology.
The permission granted by the IAEA to publish this
material is gratefully acknowledged.
Table 1 IAEA Training Curriculum on Radiation Protection in Cardiology
Table 2 List of regional training courses on radiation protection in cardiology and countries from where cardiologists participated
Table 3 Feedback from participants in the regional training courses
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|Received 12 February 2007; received in revised form 18 July
2007; accepted 20 July 2007
Correspondence: Radiological Protection of Patients Unit, International Atomic Energy Agency, Vienna, Austria. Tel.: +43-1-2600-22733; E-mail: email@example.com (Madan Rehani).
Please cite as: Rehani MM,
The IAEA’s activities on radiation protection in interventional cardiology, Biomed Imaging Interv J 2007; 3(2):e31
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