"...the study demonstrates that radiation exposure can be reduced substantially by uniformly applying the currently available strategies for dose reduction, but these strategies are used infrequently," the authors write. "...an improved education of physicians and technicians performing CCTA on these dose-saving strategies might be considered to keep the radiation dose 'as low as reasonably achievable' in every patient undergoing CCTA."

"As CCTA is being used more frequently worldwide for diagnosing coronary artery disease, all strategies for reducing radiation exposure will finally reduce the patient's lifetime cancer risks. Although the associated risk is small (estimated lifetime attributable risk of death from cancer after an abdominal CT scan is 0.02 percent) relative to the diagnostic information for most CT studies, this risk needs to be realized especially when repeated CT scans are being performed."


In an accompanying editorial, Andrew J. Einstein, M.D., Ph.D., of the Columbia University College of Physicians and Surgeons, New York, writes that there are a number of implications from this study for patient care.

"First, the study results reinforce the observation that cardiac CT angiography (CTA) is still a potentially high-dose procedure, and like all procedures involving the use of ionizing radiation, a patient-specific benefit-risk analysis should always be performed to justify the imaging study. Second, the findings suggest that dose-reduction methods can be used in the majority of patients, which should serve as a wake-up call to cardiac CT laboratories that do not routinely use these methods. ...Third, PROTECTION I reveals a degree of variability in radiation dose between sites that had not been previously appreciated, but which offers the potential to decrease radiation burden from cardiac CTA while maintaining diagnostic image quality by instituting quality improvement programs to close the gap. Fourth, the lack of clinically significant association between procedure volume and dose suggests that despite the general association between case volumes and quality of care, even many high-volume centers can benefit from such quality improvement programs."

"The international system of radiological protection stands on three principles: justification, optimization, and diagnostic reference levels. PROTECTION I provides valuable information pertaining to each of these in the context of cardiac CTA, and as such makes an important addition to the evidence base."

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