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  • 1. EUROPEAN COUNCIL OF NUCLEAR CARDIOLOGY Nuclear Cardiology in Europe National Variations in Education and Legislation June 2006
  • 2. EUROPEAN EUROPEAN COUNCIL OF NUCLEAR CARDIOLOGY Contact ECNC: Susanna Wiener Director of Operations Hollandstrasse 14 / Mezzanine A - 1020 Vienna Tel. +43-1-533-3542-27 Email: 2
  • 3. COUNCIL OF NUCLEAR CARDIOLOGY Foreword Dear Colleagues, Dear Industry Partners, ECNC, the European Council of Nuclear Cardiology, was founded in 2002 as a joint institution of the European Association of Nuclear Medicine (EANM) and the Working Group of Nuclear Cardiology of the European Society of Cardiology (ESC), in order to constitute a professional platform for the promotion of nuclear cardiology in Europe. ECNC’s major goal is to promote clinical activity in nuclear cardiology by providing standards of quality. ECNC has started professional guideline initiatives, resulting in a first published document in 2005 (Eur J Nucl Med Mol Imaging. 2005;32(7):855-97). Additionally, a high quality Nuclear Cardiology exam is available since 2004, representing another benchmark of quality (see or The vision of ECNC is to standardize clinical practice, training and accreditation in nuclear cardiology on a European level by providing a professional framework. In order to work further into this direction, a first step is to understand existing heterogeneities of regulation, training and practice in different European countries. ECNC has therefore initiated a questionnaire to analyse the present situation in 25 European countries. This questionnaire was designed by ECNC members Birger Hesse and Dominique LeGuludec. Results were obtained with the help of national societies and are presented in the following. As chairs of the ECNC we would like to thank all individuals which have contributed to this document. We are sharing the obtained information with you and hope that it will serve as a foundation for future activites to homogenize and promote the practice of nuclear cardiology in Europe. J.J. Bax F. Bengel Co-Chair ECNC Co-Chair ECNC 
  • 4. EUROPEAN Introduction Coronary Artery Disease The mortality from ischaemic heart disease in some European countries is shown in figure 1 (from P. Ghosh, F. Unger, Cardiac surgery and catheter based coronary interventions in Europe in 2002 – Executive Report of the European Heart Institute 2004) and the numbers of revascularisations is shown in table 1. Figure 1 Mortality in ischemic heart disease (< age 65) in Europe 1970–2002 14 12 10 8 6 4 2 0 1970 1975 1980 1985 1990 1995 2000 Source: WHO Nuclear Cardiology Nuclear medicine uses tracer amounts of radiopharmaceuticals to diagnose, manage or treat a wide range of conditions. The most common areas are oncology and cardiology and the most frequent nuclear cardiology investigation is myocardial perfusion scintigraphy (MPS). MPS is an important imaging technique that is effective and cost- effective for the diagnosis of coronary artery disease and for managing patients with known disease. It is an essential component of modern cardiology alongside other non- invasive and invasive techniques. It is accurate, reproducible and safe, albeit at the cost of some radiation exposure to the patient. NICE (National Institute for Clinical Excellence, UK) recommends that myocardial perfusion scintigraphy using SPECT should be the first test used for people where stress ECG may not give accurate or clear results. This can be the case for women, for people who have certain unusual patterns in the electrical activity of their heart (these patterns are detected by ECG), people with diabetes or people for whom exercise is difficult or impossible (National Institute for Clinical Excellence: Myocardial perfusion scintigraphy for the diagnosis and management of angina and myocardial infarction, Technology Appraisal 73, November 2003). 
  • 5. COUNCIL OF NUCLEAR CARDIOLOGY Table 1: Total number of coronary revascularisation procedures per million population (revasc) separated into percutaneous coronary interventions (PCI) and coronary bypass graft operations (CABG) in Europe in 2002 (with courtesy of F. Unger, from: P. Ghosh, F. Unger, Cardiac surgery and catheter based coronary interventions in Europe in 2002 – Executive Report of the European Heart Institute 2004) Table 1 Country PCI CABG Revasc Country PCI CABG Revasc Germany 2524 897 3421 Czech Republic 927 488 1415 Iceland 2021 651 2673 Spain 1175 229 1404 Belgium 1847 778 2624 Poland 906 376 1282 Norway 1683 878 2561 Hungary 721 476 1197 Switzerland 1708 683 2391 UK 747 440 1187 Ireland 1674 634 2308 Greece 741 431 1172 Austria 1659 557 2215 Lithuania 616 492 1107 Denmark 1359 688 2047 Portugal 673 297 970 Sweden 1366 658 2024 Estonia 486 353 840 France 1579 316 1894 Latvia 518 248 766 Netherlands 1238 619 1857 Bulgaria 213 87 300 Finland 1034 803 1836 Romania 69 40 109 Italy 1307 403 1710 As a technique that uses tracer amounts of radiopharmaceuticals, the practice of nuclear testing is tightly regulated. The relevant regulations are mainly national and so co-ordination and harmonisation between nations is important if MPS is to be used appropriately for the benefit of patients throughout Europe. There is evidence that the technique is not used appropriately in all countries and this is reflected in wide variations of practice both between and within European nations. The recently published European procedural guidelines for MPS will hopefully reduce these variations but differences in national regulations and practice are likely to remain unless there is a concerted effort to harmonise practice (cf. e.g. table 2 in Hesse B, Tägil K, Cuocolo A, Anagnostopoulos C, Bardiés M, Bax J, Bengel F, Sokole EB, Davies G, Dondi M, et al. EANM/ESC procedural guidelines for myocardial perfusion imaging in nuclear cardiology. Eur J Nucl Med 2005; 32:855-97). Radionuclide imaging and therapeutic procedures are undertaken by a number of different medical specialists including nuclear physicians, clinical physiologists, medical physicists, radiologists, cardiologists and oncologists. Sometimes different specialists work together to provide a service and sometimes organ-based specialists practice single organ nuclear medicine techniques, such as the cardiologist with expertise who specialises in nuclear cardiology or cardiac imaging in general. The multi-disciplinary nature of the speciality is one of its strengths although it also poses unique problems for training, accreditation and regulation. Nuclear medicine has been an independent medical specialty in Europe since 1988. The European Union of Medical Specialists (UEMS) requires a minimum duration of specialist training of 5 years (Union Européene des Médecins Spécialistes, Section of Nuclear Medicine, European Board of Nuclear 
  • 6. EUROPEAN Medicine, Syllabus for Postgraduate Specialisation in Nuclear Medicine, 2002 Update), but a longer period may be required if nuclear medicine is to be combined with other specialist interests. In those countries, where the total duration of the specialised training is 4 years (which corresponds with the minimum duration in the Directive of the EC), 3 years should be devoted to NM and 1 year to other specialities. Informal observation of nuclear cardiology practice in Europe and elsewhere suggests that MPS is most valuable when the specialists involved have expertise in both nuclear medicine and cardiology or where nuclear physician and cardiologist collaborate closely. Developing the concept of special expertise in nuclear cardiology for specialists in nuclear medicine and/or cardiology is increasingly important and attractive. There is therefore a need to define and agree the generic skills and experience that represent the clinical as well as the technical body of knowledge in nuclear cardiology. The premise is that specialists from several backgrounds are capable of practising nuclear cardiology but that training, accreditation and practice must be of a uniform and high standard whatever the background of the expert. As a prelude to these discussions we have surveyed some aspects of nuclear medicine training and nuclear cardiology practice in Europe. Methods We sent a questionnaire to 31 National Nuclear Medicine Societies and to 40 National Cardiology Societies and we received 25 replies representing Austria, Belgium, Bulgaria, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Israel, Italy, the Netherlands, Norway, Poland, Portugal, Romania, Russia, Spain, Sweden, Switzerland, Turkey and the United Kingdom (UK). Results Nuclear medicine is a recognised speciality in 24 of the 25 countries. Nuclear medicine specialist training consists of theoretical and practical components in all countries but content and duration vary (table 2). Radionuclide imaging procedures can be practised by nuclear physicians in all countries but also by other specialists in some and by all physicians (with appropriate training) in others (figure 2). In addition to specialist training, all countries require a specialist to have a specific licence to administer radiopharmaceuticals but access to such a licence is variable (figure 3 and table 3). The licence is available to specialists other than nuclear physicians in Bulgaria, Denmark, Hungary, Spain and the UK. A licence restricted to nuclear cardiology is available in Austria, Czech Republic, Estonia, Germany, Norway and Poland. A restricted practice can be conducted by a non-licence holder in collaboration with a licence holder in Israel, the Netherlands, Norway, Poland, Sweden and the UK. 6
  • 7. COUNCIL OF NUCLEAR CARDIOLOGY Table 2: Theoretical and Practical Education in Nuclear Medicine Country Theory Courses Hours Practice in nuclear Documented NM medicine examinations Austria course in radiation protection, incl. 2 34 5 years (incl. 1 year exams radio-diagnostics) Belgium courses during 3 years 100 3 years Bulgaria not detailed 4 years Cyprus education in foreign country 5 years Czech Republic courses as recommended by ESNM 180 3 years (European School of Nuclear Medicine) Denmark courses during 3 years 310 4.5 years Estonia at the moment nuclear medicine is not recognized as a speciality Finland administration & leadership education 20 4 years 9 months all fields of NM 60 (including 3-9 mo courses have to be completed by radiology) a written exam, further no binding regulations France theory courses (physics, dosimetry, 186 2 years radiobiology, radioprotection, 1 year radiology radiopharmacy etc.), clinical courses 125 complimentary courses 100 Germany radio protection, further no binding 3 days 4 years 2.800 (may be reduced in the regulations future) incl. documentation Greece courses during 1 year 4 years Hungary not detailed 5 years 500 patient studies Italy during 5 years appr. 500 of which: 5 years > 500 patient studies theory courses 350 and adequate number of integrative subjects 100 diagnostic procedures, radio- metabolic diagnostic Netherlands national degree in radiation protection 2,5- 2,75 (incl. 3-6 (level 3), NVNG-prescribed courses months of radiology) and tests, fulfilment of the NVNG (Nederlandse Vereniging voor Nucleaire Geneeskunde ) criteria Norway nuclear physics, radiation protection, 260 5 years (incl. instrumentation radiology/clinical chemistry research or other speciality) Poland not detailed 3 years Portugal 1 year 100 4 years radio-pharmacy, radiation protection, 3 mths. radiology physics, instrumentation and quality (medical imaging) control Russia during 2 years 2 years numbers of cases can general radiology, radio-oncology, radio be determined by the protection, exam for nuclear medicine candidate Spain 6 courses 160 4 years radiation protection, nuclear medicine, nuclear cardiology, nuclear neurology, PET+quality control Sweden not detailed 5 years Switzerland during 4 years 4 years 3.500 (including 500 nuclear completed by a federal radioprotection cardiology procedures, 400 course, all sanctioned by specific exams SPECT/CT, PET/CT) United Kingdom not detailed 4 years 500 MPS (+general NM) 
  • 8. EUROPEAN Who is licensed to practice NM? Figure 2 Regulations on the practice of NM AU, FIN, GER, ISR, RUS Poland, UK All countries Regulations for availability of licence to order / inject radiopharmaceuticals for non-NM specialists Figure 3 Regulations for licence 1 2 3 1: Bulgaria, Denmark, Hungary, Spain, UK; 2: Austria, Czech Republic, Estonia, Germany, Norway, Poland; 3: Israel, the Netherlands, Norway, Poland, Sweden, UK (e.g. cardiologist performing stress test) 
  • 9. COUNCIL OF NUCLEAR CARDIOLOGY Licences to administer radiopharmaceuticals are issued by national authorities such as ministries, environmental or atomic agencies but the requirements are variable. In Finland and Israel the licence is awarded to the hospital department, which is required to ensure that only suitably trained staff perform nuclear medicine procedures. In Hungary physicians with a radiation protection certificate can obtain a licence to administer radiopharmaceuticals without further training. In all other countries nuclear medicine specialists can obtain a licence without additional training (table 3). Nuclear cardiology is not a recognised specialty in any of the countries surveyed but most countries with the exception of Bulgaria, Denmark and Spain accept training in more than one specialty Nuclear physicians can perform stress tests in most countries; however, in Belgium, France, Israel, Romania and Russia it is common practice that they cooperate with a cardiologist. Specific training for stress testing is required in some European countries (Austria, Bulgaria, Estonia, Finland, Hungary, Italy, the Netherlands, Norway, Portugal, Sweden, Switzerland and Turkey). Table 3 Requirements to obtain a licence Austria course in radiation protection for open sources Belgium to be NM specialist Bulgaria 1 week course of radiation protection every 5 yrs with examination Cyprus to be NM specialist Czech Republic to be NM specialist Denmark to be NM specialist, for ordering course and examination Finland licence is given to hospitals (institution to fulfil the criteria to possess and to handle radiopharmaceuticals), responsibility of hospitals that employees have sufficient training France to be NM specialist Germany course for radiation security Greece to be NM specialist Hungary MD and radiation protection certificate Israel licence is given to departments, which have to fulfil the criteria, not to specialists Italy to be NM specialist Netherlands to order radiopharmaceuticals, the institution has to fulfil requirements to possess and to handle radiopharmaceuticals. to inject radiopharmaceuticals, a physician must have at least a level 3 degree in radiation protection Norway to be NM specialist Portugal to be NM specialist Russia 2 years training as NM specialist Spain course and examination Switzerland to be NM specialist Turkey to be NM specialist and to be registered at the Turkish Atomic Agency United Kingdom training equivalent of that of a nuclear physician 
  • 10. EUROPEAN Figure 4 Shows estimates of the percentages of MPS studies performed in hospitals and in private clinics. In Germany, Greece, Israel and Spain, the number of myocardial SPECT studies in private clinics exceeds those performed in hospitals, whereas in France, Italy and Portugal the distribution is similar. In the majority of countries private clinics play a minor role or don’t exist at all. Myocardial SPECT Studies in Hospitals versus Private Clinics Private Clinics Hospitals Austria Bulgaria Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Israel Italy Netherlands Norway Poland Portugal Romania Russia Spain Sweden Switzerland Turkey United Kingdom Figure 5 Shows the estimated percentages of studies according to nature of the specialist. Nuclear physicians are the main specialists in most countries with the exception of Israel, Poland and Spain where cardiologists predominate. Other physicians such as cardiologists and radiologists are in the minority in most countries with the exception of the United Kingdom. Percentages of Myocardial SPECT Studies Performed under the Supervision of NM Specialist Cardiologist Both Radiologist Others Austria Belgium Bulgaria Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Israel Italy Netherlands Norway Poland Portugal Romania Russia Spain Sweden Switzerland Turkey United Kingdom 10
  • 11. COUNCIL OF NUCLEAR CARDIOLOGY Comments Cardiovascular deaths have decreased and the number of revascularisation procedures has increased in Europe over the last 10 years, although it is not clear how closely the two are related (figure 1). Over the same period the number of MPS studies has also grown although considerably less than in USA. Variations in MPS practice in Europe are pronounced, including numbers of procedures, waiting times and stress and imaging procedures. Although these variations may be caused partly by differences in healthcare structure and reimbursement, differences in training and regulation are also important. In contrast, in the USA the more uniform training and regulatory environment has coincided with an increase in the numbers of MPS procedures performed. 40% of MPS studies are performed by cardiologists in the USA. Steps that will promote appropriate use of nuclear cardiology in Europe include • Collaboration between the UEMS, ESC, EANM, and national professional bodies to define, promote and monitor common standards of nuclear cardiology practice • A professional examination to allow practitioners from all backgrounds to demonstrate high standards of practice that are common to each country • Involvement of professional, regulatory and financial bodies to plan the provision of nuclear cardiology services alongside competing demands on professional time and resources • Empowerment and recognition of specialists with appropriate training but from different backgrounds to provide nuclear cardiology services Acknowledgements: This survey was sponsored by grants from Bristol-Myers- Squibb Medical Imaging, GE-Healthcare Bio Sciences and Tyco-Healthcare. 11