NASCI North American Society for Cardiac Imaging

The North American Society for Cardiac Imaging (NASCI) is an
international organization dedicated to the advancement of cardiovascular imaging.

	NASCI Position Paper on Cardiac Imaging sent to Robert Hattery, MD, American Board of Radiology January, 2003
The North American Society for Cardiac Imaging recognizes that recent developments in MRI and CT of the heart will very likely have a positive impact on patient care. These developments create possibilities for greatly improved and cost-effective diagnosis of heart disease – the most significant health care challenge facing the developed world. While radiologists are very familiar with the technology of MRI and CT and their use in multiple organ systems, very few are expert in the applications of MRI and CT to the evaluation of ischemic heart disease and other cardiac problems. A paradox of modern practice is that while radiologists may be very familiar with uncommon lesions of many different organ systems, they have little formal training in imaging the number one health problem in this country, coronary artery disease. This deficiency reflects the traditional structure of radiology residency training programs and the expectation among radiology trainees that they will have little, if any, direct involvement in the performance and interpretation of cardiac imaging studies when they enter practice.

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Radiologists have always correctly felt a strong responsibility to be highly knowledgeable and actively involved in the entire spectrum of diagnostic imaging and image-guided interventions. As physicians whose full-time profession mandates the appropriate use of complex imaging technologies, radiologists are well poised to provide the most accurate interpretation of imaging studies, and to best assure the radiation safety of our patients.

A recent study has revealed that cardiovascular imaging already constitutes a very large component of noninvasive diagnostic imaging – 18% of all imaging studies1. The overwhelming majority of these studies currently involve ultrasound and radionuclide imaging services, with diagnostic interpretation provided by physicians in the Cardiology and Nuclear Medicine communities. However, recent technological developments make it likely that MRI and CT will assume an increasing role in cardiac imaging for (1) screening for coronary disease through calcium scoring, (2) direct imaging of the coronary arteries, (3) definition of plaque composition and determination of which plaques are vulnerable, (4) assessment of cardiac function, (5) assessment of myocardial perfusion and viability, (6) sizing of infarcts and characterizing them as subendocardial or transmural, (7) demonstration of atrial and pulmonary vein anatomy to help pinpoint the location of an abnormal electrical focus responsible for atrial fibrillation prior to ablation, and (8) imaging of complex chamber anatomy in children with congenital heart disease. As these technologies reach maturity, there will be insufficient expertise within the entire medical community, let alone among radiologists, to meet the demand for cardiac imaging services involving MRI and CT.

At the 2002 RSNA there was considerable emphasis on the use of CT, MR, and PET in cardiac diagnosis. It is clear that these modalities are reaching the stage of clinical relevance. Interestingly, most of the research presented came from Europe, Japan, or in some cases cardiologists from American institutions. The low level of participation by American radiologists was striking, and the implications for provision of MRI and CT cardiac imaging services to an expanding population is a cause for concern. The Board of NASCI feels strongly that we owe it to our patients to provide the best services modern technology can offer them, and we owe it to our young radiology trainees to provide them with the training and education they need to help provide such services.

While most radiologists seem to agree that their community should be fully involved in CT and MR of the heart (as we are in the use of these modalities in all other organs), this will not happen unless education and research in cardiac imaging among radiologists sharply increase. The leaders in our specialty responsible for training, including SCARD, AUR, APDR, and Radiology RRC, will need to take concerted action to raise the level of training and foster enthusiasm for cardiac imaging among young radiologists. NASCI is committed to meeting with these organizations in the upcoming year to help in anyway possible to address the situation. It is also a well-known fact that radiology residents focus their attention on the material slated for the ABR written and oral exams. The board examinations essentially define the residents’ reading, training and radiology education. Although the cardiopulmonary section of the oral board examination currently includes cardiac cases for approximately 50% of its questions, there is a generally held perception by the residents that not much is expected of them in terms of cardiac imaging knowledge and hence they do not give cardiac imaging the emphasis it currently deserves. We believe this misperception would be substantially addressed by a predefined standard in cardiac imaging which would be a requirement to pass the board examination. This is also critically important at this point in time since there is every expectation that radiology trainees will need, or at least have the opportunity to utilize, cardiac imaging skills in their later practice. We suggest that the ABR could help rectify this by specifically emphasizing cardiac imaging in future Board examinations. If that happens, residents will quickly develop an interest in learning about the heart, and residency programs will be stimulated to begin providing them with an appropriate education in the subject. Increased interest in and knowledge of cardiac imaging among young radiologists will undoubtedly spur some of them to make it a career choice and become involved in cardiac research and teaching.

NASCI recognizes that the ABR has struggled with this issue for some time without settling on a practical method of integrating a full cardiac imaging section into the existing oral Board examination framework. We are confident that, once the ABR declares that expertise in non-invasive cardiac imaging is one of the core competencies that all radiology residents must master for certification, the Board will be capable of addressing the technicalities and particulars of incorporating a cardiac section successfully. However this change is accomplished is less important than a clear indication from the ABR that there is a change from the status quo in that cardiac imaging is now one of the core competencies to be passed by all applicants for certification.

NASCI remains committed to assisting the board in implementing any agreed upon plan, including supplying case material and examiners. Additionally, our members are dedicated to assisting those training programs that lack adequate resources to prepare residents in cardiac imaging by providing course brochures, syllabi, reading lists, and web-based self-teaching programs. We plan to offer didactic courses for residents regionally throughout the country. Our members are willing to participate in a training program’s resident education course, should this be desired.

What will happen if our community fails to act quickly? We predict there would be serious consequences to our entire field. The potential of MRI and CT is clearly recognized by physicians in other specialties, and it is highly likely that any void caused by radiologist inactivity will be filled by other practitioners. This may result in inappropriate utilization, sub-optimal quality control, and ballooning health care costs. The radiology community will thereby have abdicated its responsibility to all its constituencies – patients, referring physicians, and the healthcare system itself.

In summary, NASCI is confident that CT and MRI are currently poised to assume a major role in cardiac imaging. As this portends an encouraging future for radiologists engaged in cardiac imaging, we are convinced that the radiology community is required to act promptly so that we do not miss this opportunity to serve the individual patient’s noninvasive cardiac imaging needs. NASCI is committed to working with the leading organizations of radiology to implement this change in our culture; a change which reflects the current status of cardiac imaging in radiology at this point in the evolution of our specialty.

1 Levin DC, Parker L, Sunshine JH, Pentecost MJ. Cardiovascular Imaging: Who Does It and How Important Is It to the Practice of Radiology? AJR:178,February 2002 303-306

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