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  1. 1. Original article The future of cardiovascular imaging and non-invasive diagnosis A joint statement from the European Association of Echocardiography, the Working Groups on Cardiovascular Magnetic Resonance, Computers in Cardiology, and Nuclear Cardiology, of the European Society of Cardiology, the European Association of Nuclear Medicine and the Association for European Paediatric Cardiology Alan G. Fraser1, Peter T. Buser2, Jeroen J. Bax4, Willem R. Dassen3, Petros Nihoyannopoulos1, Jürg Schwitter2, Juhani M. Knuuti4, Martin Höher3, Frank Bengel5, András Szatmári6 1 European Association of Echocardiography, ESC Office for Associations, The European Heart House, 2035 Route des Colles, B.P. 179 - Les Templiers, 06903 Sophia Antipolis, France 2 Working Group on Cardiovascular Magnetic Resonance, European Society of Cardiology, Sophia Antipolis, France 3 Working Group on Computers in Cardiology, European Society of Cardiology, Sophia Antipolis, France 4 Working Group on Nuclear Cardiology, European Society of Cardiology, Sophia Antipolis, France 5 European Association of Nuclear Medicine, Hollandstrasse 14, A-1020 Vienna, Austria 6 European Society for Paediatric Cardiology, Hungarian Center for Pediatric Cardiology, 29 Haller, P.O. Box 88, 1450 Budapest, Hungary Received: 20 April 2006 / Accepted: 2 May 2006 / Published online: 4 July 2006 © Springer-Verlag 2006 Abstract. Advances in medical imaging now make it Eur J Nucl Med Mol Imaging (2006) 33:955–959 possible to investigate any patient with cardiovascular DOI 10.1007/s00259-006-0201-8 disease using multiple methods which vary widely in their technical requirements, benefits, limitations and costs. The appropriate use of alternative tests requires their integration into joint clinical diagnostic services where experts in all methods collaborate. This statement summarises the Introduction principles that should guide developments in cardiovascu- lar diagnostic services. Continuing developments in medical technology and clinical research constantly expand the range of imaging tests and diagnostic measurements. Nowhere is this more Keywords: Cardiovascular imaging – Clinical services – true than in cardiology, where the choice of investigations Training – Guidelines – Research includes different technologies with overlapping capabil- ities. How should clinicians, hospital managers and funding bodies respond and adapt to these changes? How should the demands of different approaches be reconciled to the benefit of patients? What are the implications for the education and training of future cardiologists, cardiac surgeons and other specialists in cardiovascular imaging? This paper is published simultaneously in the European Heart Journal (2006;27:1750–1753) and in the European Journal of Echocardiography (2006;7:268–273). Collaboration between imaging subspecialties Alan G. Fraser ()) Important information for the diagnosis and management European Association of Echocardiography, ESC Office for of patients with cardiovascular disease can be provided by Associations, The European Heart House, 2035 Route des Colles, B.P. 179 - Les Templiers, ultrasound examination including echocardiography, by 06903 Sophia Antipolis, France scintigraphy using single photon and positron emitting e-mail: fraserag@cf.ac.uk radiopharmaceuticals, by magnetic resonance with or Tel.: +44-29-20743489, Fax: +44-29-20743500 without a paramagnetic imaging agent, and by X-ray European Journal of Nuclear Medicine and Molecular Imaging Vol. 33, No. 8, August 2006
  2. 2. 956 computed tomography or cardiac catheterisation and Collaboration should of course also embrace non- angiography with the injection of an iodinated contrast invasive and invasive services since these approaches are agent. These alternatives encompass a wide spectrum from complementary rather than competitive. This can be non-invasive investigations with no associated risks, achieved when there are appropriate funding and resources through non-invasive tests that require exposure to ionising for both. Colleagues who specialise in either approach radiation, to invasive procedures with a small risk of major should have some education and experience in all imaging complications. modalities. Diagnostic cardiac catheterisation is increasingly con- ducted by cardiologists who also perform interventions, and this trend is likely to continue. The progression to Evidence-based diagnostic practice therapy by percutaneous intervention makes coronary arteriography a unique imaging modality because of its Best diagnostic practice should be based on impartial direct and immediate link to treatment, but the limitations professional advice. Some investigations such as the of arteriography, well demonstrated by intravascular ultra- exercise ECG were widely implemented before they had sound, mean that it may be appropriate in non-urgent cases been adequately assessed, and some new technologies are to reserve the invasive approach for patients in whom evolving so fast that thorough assessment is very difficult. abnormal haemodynamic function or ischaemia has Nonetheless, investment in new imaging technologies for already been confirmed. Invasive tests of perfusion reserve routine practice can only be justified when there is clear can aid clinical decision-making during a coronary proce- scientific evidence that the new modality is substantially dure, but with this exception precise haemodynamic better and preferably also more cost-effective than prior investigation of cardiovascular pathophysiology is now alternatives. performed during cardiac catheterisation less frequently Talk of “winners” and “losers”, and confrontational than before. debates, are inappropriate. Advice should be based on clear The selection of which test to use to establish a data from well-conducted research establishing accuracy diagnosis of abnormal function should be based on a broad (preferably against an independent reference criterion), perspective and expert knowledge of what each available reproducibility and safety. Most importantly, diagnostic technique can offer. This is possible only if colleagues tests should be evaluated and compared for their impact on experienced in each imaging modality collaborate fully, so clinical outcomes, not just on their attainment of more that choices are not constrained by knowledge or practice precise diagnoses or more impressive images. Relevant limited to a single technology. outcomes might include a reduction in complications or It follows that experts in different imaging sub- hospital admissions, or an improvement in quality of life, specialties should produce joint recommendations and as well as survival. guidelines, from which shared diagnostic protocols can be Different imaging technologies and tests may be developed and promulgated. These may require the appropriate for screening asymptomatic individuals or for development of new criteria for summarising the outcome identifying a disease and then monitoring its response to of diagnostic studies that vary from those now in common treatment. The utility of applying a test may vary between usage for the assessment of therapeutic studies [1]. In populations, and within populations between individuals addition, when there is a diagnostic component of general with different pre-test probabilities of disease. Some tests clinical guidelines, then an expert in all the relevant may be very effective in the controlled conditions of a imaging modalities should be included in the writing clinical research study, but inefficient in routine clinical group. practice. Feasibility and costs can vary greatly between Fig. 1. Suggested organisation Cardiology of joint, multidisciplinary Nuclear diagnostic services. SCINT Medicine Radiology nuclear scintigraphy, PET posi- tron emission tomography, CT X-ray computed tomography, Joint Cardiac CMR cardiovascular magnetic Imaging Group resonance Common • Ultrasound Patients requiring diagnostic • SCINT / PET Clinical impact cardiovascular protocols • CT and end-points investigation and • CMR pathways • Angiography European Journal of Nuclear Medicine and Molecular Imaging Vol. 33, No. 8, August 2006
  3. 3. 957 technologies that are capable of demonstrating the same feedback from their impact on outcomes (see Fig. 1), and diagnoses. When alternative tests are equally useful, their also to take account of the preferences of patients. safety and convenience to the patient may differ. All these A common channel for processing requests for issues need to be assessed and acknowledged in recom- sophisticated diagnostic tests is preferred, since it allows mendations. An organisational framework could usefully recommendation or selection by experts of the most be established for the systematic evaluation and meta- appropriate test in any specific circumstance. It is important analysis of diagnostic tests, analogous to the Cochrane to avoid duplication of tests and to prioritise locally collaborations that now overview therapeutic trials [2] according to available facilities and expertise. Selection of (http://www.cochrane.org). a single test in a patient, when it has been shown to have clinical value, is preferred to a succession of tests based on different technologies, used in turn after each previous test Joint imaging strategies has given ambiguous or uncertain results. Ideally, algorithms for the investigation of cardiac The clinical use of diagnostic imaging technologies patients by tomographic imaging should be established available in a cardiac unit and hospital should be jointly by cardiologists and radiologists. If new methods coordinated through a joint service (Fig. 1). This should are to be properly evaluated and implemented, then access be managed by a group of specialists including clinicians should be unhindered. The cardiological indications for and radiologists and chaired by an expert in several best use and cost-effectiveness of magnetic resonance and cardiovascular imaging modalities. There is much more to X-ray computed tomographic imaging need to be estab- “imaging” than pictures—so colleagues with clinical and lished by clinical research in departments where there are technical expertise together can exploit the potential of new no major financial barriers to their use, and where techniques for studying both anatomy and pathophysiolo- equivalent expertise is available for all modalities that are gy. Rather than “imaging”, perhaps a new term will emerge compared. as current subspecialties converge and a new type of multi- When direct access to diagnostic services is offered to modality diagnostic specialist evolves. non-cardiovascular specialists or to primary care physi- It is established that echocardiography and coronary cians, then patients should be referred to a joint diagnostic arteriography are performed within cardiology departments team; the investigation will then be performed either by a under the supervision of cardiologists. Nuclear cardiology cardiologist or by a cardiovascular radiologist as part of the is usually managed by a team of experts including combined service. Ideally, reports should be issued jointly physicists or nuclear medicine physicians and cardiolo- by cardiologists and radiologists, but in principle a study gists. The integration of these technologies into daily can be performed and interpreted by any appropriately practice has greatly enhanced their diagnostic impact and trained specialist. indirectly their therapeutic potential. The newer tomo- graphic imaging techniques such as magnetic resonance and X-ray computed tomography have been developed by Priorities for research radiological and cardiological research groups, and it is appropriate and timely now to integrate them also into The prevailing trend is to emphasise the importance of clinical practice. This process will be helped by a shift of basic biomedical, molecular and genetic research [3] and to diagnostic expertise, from specialising in a particular allocate the largest share of resources to these fields of technique that is applied by cross-sectional imaging to enquiry. These programmes have significantly advanced multiple organs, to an organ- or system-based approach our understanding of the mechanisms of disease, but in where the diagnostic expert is more concerned with order to translate developments into any major clinical function, the integration of results into clinical decision- impact on the prevalence, morbidity or mortality of making, and the impact of diagnostic imaging on clinical common cardiovascular diseases such as atherosclerosis, outcomes. hypertension, diabetes and heart failure, it is necessary also For logistic and physical reasons, it may not be feasible to develop more sophisticated tests for the precise to locate tomographic imaging machines geographically measurement of vascular and cardiac function and the within the cardiological departments of many hospitals. effects of new treatments. Clinical diagnostic expertise This need not prevent planning for such an arrangement in with sensitive and accurate characterisation of early disease future, when resources and local circumstances or new and its progression is required to assist further progress, buildings allow it. What is much more important than the and cardiovascular imaging has a key role to play in location of equipment or the background and specialty of meeting this challenge. The best basic science needs to be the staff who perform examinations, however, is that all combined with the best imaging methods. disciplines work together and that services are coordinated. Governmental and European Union grant-funding bod- A joint department is not necessary, but a joint service ies should allocate funds to joint cardiovascular research where patients follow agreed common clinical investiga- initiatives that encompass clinical research in diagnostic tive pathways should become the norm. These pathways imaging in conjunction with research in mechanical and should be reviewed regularly and modified in response to electronic engineering, informatics and biostatistics, and European Journal of Nuclear Medicine and Molecular Imaging Vol. 33, No. 8, August 2006
  4. 4. 958 epidemiology. Medical equipment companies cannot be imaging. Expertise in these aspects is important for the safe expected to fund such research; collaboration between and appropriate clinical implementation of advanced universities and research engineers in industry is very diagnostic imaging techniques, and therefore radiologists important, but major clinical research should be conducted and physicists have a particular contribution to make to without specific company sponsorship. joint diagnostic services. At the same time, radiologists The increasing precision of non-invasive diagnosis who wish to become more closely involved in a clinical paradoxically makes it more difficult to determine whether service should obtain some experience during their training or not a patient has subclinical disease, because the within that clinical specialty, both of mechanisms of influences or associations of risk factors and age on arterial disease and of the clinical utility of the diagnostic tests. and myocardial structure and function can now be Acquiring theoretical and practical expertise in several identified. This makes it necessary to establish very large diagnostic techniques presents major challenges, but there databases of normal subjects which are relevant to each is a need for imaging specialists who have multiple skills. country or major region. Population studies with precise The goal of joint educational programmes should be to phenotypic definition by new diagnostic techniques, train cardiologists or cardiovascular radiologists who have undertaken in conjunction with genetic investigations, the knowledge, skills and experience to assume clinical may yield important insights into the interaction of genetic responsibility for organising, supervising and reporting and environmental influences and thereby offer directions diagnostic tests in at least two different modalities (and for new epidemiological approaches to the prevention of ideally, in all current modalities). Physicians who have common diseases. Such projects will need to be organised clinical responsibility for non-invasive diagnostic imaging as multicentre collaborations. should have obtained national or European accreditation in Academic cardiologists who organise large clinical their chosen subspecialties [4]; cardiologists in this role trials of new drugs with support from pharmaceutical should have completed a special fellowship in advanced companies should take expert advice about recent diag- diagnostic methods in addition to general cardiological nostic advances whenever they design a new study. This training. Accreditation should be maintained through will avoid any time-lag between testing new drugs and participation in continuing medical education, which implementing new tests for detecting changes with optimal should be supported financially by employers. sensitivity and accuracy. Cardiac departments need at least as many non-invasive Universities should recruit, encourage and support experts as colleagues who perform coronary interventions, academic cardiologists to develop and retain expertise in if advances in diagnosis and monitoring of disease are to be clinical physiology and diagnosis. These are necessary and implemented fully for the benefit of patients. Doctors in legitimate interests for an academic department that should training who want to choose non-invasive cardiology as be developed in conjunction with expertise in basic science their special interest should be rewarded similarly to those and genetics. working in other subspecialties. Recruitment should be based on interest and not skewed by disincentives caused by extraneous non-clinical factors. Implications for training Clinical cardiologists should not personally perform or report investigations such as echocardiography or scintig- There should be joint educational programmes that rotate raphy unless they keep up-to-date, for example by fellows who are training in cardiovascular medicine, participating in hospital reporting sessions and case-review between echocardiography, cardiovascular magnetic reso- conferences and by attending national or international nance, nuclear cardiology and X-ray computed tomogra- courses and conferences. Cardiac surgeons in training phy, with optional experience for example in positron should undertake specific education in non-invasive emission tomography or vascular ultrasound if it is cardiovascular imaging as well as in the interpretation of available. Training time should be timetabled and pro- arteriography, since they need to understand the potential tected. For prospective general cardiologists, this experi- and limitations of any technique that is used to establish a ence is perhaps more important than time allocated for preoperative diagnosis. They should also be familiar with training in diagnostic cardiac catheterisation, since the non- techniques that are used to assess the outcome of surgery, invasive diagnostic department is now the place where such as intraoperative transoesophageal echocardiography. fellows observe and learn in detail about cardiovascular A component of continuing medical education for all function, myocardial perfusion and pathophysiology. Such cardiologists and cardiac surgeons should relate to experience provides a sound understanding of mechanisms advances in diagnostic imaging and their clinical imple- of disease, which forms the essential foundation for logical mentation and value. clinical practice. Practitioners who undertake limited diagnostic imaging, Cardiovascular radiologists have their own training for example with hand-held echocardiographic machines, programme, which includes particular experience of radi- should also complete approved training and participate in ation safety, medical physics and technological factors appropriate continuing medical education. required to perform, optimise and interpret tomographic European Journal of Nuclear Medicine and Molecular Imaging Vol. 33, No. 8, August 2006
  5. 5. 959 Conclusions Acknowledgements. This document has been reviewed and endorsed by the members of the Board of the European Association of Echocardiography, by the members of the Nuclei of the Working – Experts in different imaging modalities should collabo- Groups on Cardiovascular Magnetic Resonance, Computers in rate not compete Cardiology, and Nuclear Cardiology of the European Society of – Joint clinical services and common diagnostic pathways Cardiology, and by members of the Cardiovascular Committee of the European Association of Nuclear Medicine. We thank all our should be developed colleagues for their helpful comments. We also thank Professor – Future diagnostic specialists should be trained in several Matthijs Oudkerk, President of the European Society of Cardiac imaging modalities Radiology, for his helpful advice. – Diagnostic tests should be evaluated by their impact on clinical outcomes – Diagnostic guidelines should compare all methods that References can be applied to a particular clinical question – New criteria should be developed for judging the quality 1. Gibbons RJ, Smith S, Antman E. American College of of diagnostic research Cardiology/American Heart Association Clinical Practice – Expertise in imaging should be encouraged and funded Guidelines: Part I. Where do they come from? Circulation as an integral component of basic, epidemiological and 2003;107:2979–2986 clinical collaborative research networks 2. Ebrahim S. The Cochrane Collaboration: an international effort for preparing, maintaining and disseminating systematic re- views of the effects of health care in cardiology. Cardiovasc Our professional groups will now pursue these Risk Factors 1999;7:216–222 objectives jointly, both within the European Society of 3. Martin J, Nimmesgern E, editors. The future of cardiovascular Cardiology and also through collaborations between the research in Europe. Brussels: European Commission; 2005 4. Fox KF, Flachskampf F, Luis Zamorano J, Badano L, Fraser medical professional societies in Europe that are concerned AG, Pinto FJ. Report on the first written exam held as part of with diagnostic imaging in cardiovascular disease. the European Association of Echocardiography Accreditation Process in Adult Transthoracic Echocardiography. Eur J Echocardiogr 2004;5:320–325 European Journal of Nuclear Medicine and Molecular Imaging Vol. 33, No. 8, August 2006