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What is the future for cardiac radiology?
ClinicalRadiology (1989)40, 451-452
What is the Future for Cardiac Radiology? p. W I L D E -
Bristol Royal Infirmary, Bristol BS2 8 H W
The present position of cardiac radiology in Britain today reflects major inconsistencies between the needs of patients with cardiac disease and the response of diagnostic radiologists to those needs. Cardiac disease is the major cause of death and morbidity in this country today, affecting patients of all ages from the fetus to the elderly; in spite of extensive research and efforts at prevention, its overall incidence is changing very little. Recent reports suggest a reduction in the high incidence of coronary heart disease over the last 10 to 15 years but it is hard to tell if this is significant or if it will be sustained. The incidence of congenital heart disease has not changed for many decades and the increase in degenerative heart disease in our expanding elderly population has replaced rheumatic heart disease as the major cause of adult valvular dysfunction. In the last 30 years medical and surgical treatments for cardiac disease have dramatically improved and they have enhanced the lifestyle of huge numbers of patients whose symptoms have been reduced or abolished. There is current speculation that the early signs of decreasing coronary mortality may be due at least in part to life prolonging treatments. Such effective treatments must be preceded by accurate diagnosis, a large part of which depends on cardiac imaging techniques. Coronary arteriography is an essential precursor to coronary surgery and it is probable that it is now the most common invasive imaging technique with approximately 30-40000 coronary arteriograms being performed annually in the UK. Echocardiography has revolutionised the practice of cardiology; not only can structural abnormalities of valves and chambers be clearly and noninvasively delineated, but haemodynamic parameters such as valve pressure gradients and pulmonary artery pressures can be determined accurately. Computed tomography is commonly used to diagnose aortic root dissection and is the examination of choice for masses and turnouts adjacent to the heart. Isotope scanning gives important functional insights into the heart and now magnetic resonance imaging combines functional and anatomical cardiac assessment is a new and exciting way. Digital angiography is becoming well adapted to the assessment of the moving heart and can simplify the assessment ofventricular function. In some centres digital cardiac studies have taken over the angiographic diagnosis of congenital heart disease. The plain chest radiograph must not be forgotten in this list of complex imaging modalities. This simple examination often allows accurate diagnosis of specific cardiac pathology and still forms the basis for many decisions in the management of cardiac patients, showing changing appearances of heart and lungs as disease or treatment progresses. Unfortunately, apart from interpreting chest radiographs most radiologists play a small part in this large and expanding field of medical technology. The overwhelming majority of coronary arteriograms are performed by cardiologists in spite of this being an investigation requiring expert knowledge of radiographic imaging
techniques, radiation hazards, and interpretation skills needed during as well as after the examination. Skilled echocardiography combines an understanding of diagnostic ultrasound, cardiac function and pathology with practical experience. Radiologists are fortunate to have a formal training period in which it can be taught; cardiologists by contrast usually have no such opportunity and have to pick up the skills 'on the job'. In spite of this most echocardiograms are performed by cardiologists or cardiological technicians. In addition to a heavy clinical workload with its ever increasing demands, there are numerous skills to be acquired by clinical cardiologists. These include resting and stress electrocardiography, 24 hour monitoring, electrophysiology, pacemaking and of course the gamut of cardiac drug therapies. Additionally many clinical cardiologists attempt to be fully conversant with the complete range of cardiac imaging techniques. The limitations in junior medical staff manpower as a consequence of government policy in 'Achieving a Balance' have increased this problem and most cardiology departments are now hard pressed to keep up with the clinical workload. This would be the case in all clinical disciplines if they performed their own diagnostic imaging! In every other branch of medicine modern radiologists are happy to advertise new technological skills to their colleagues and push back frontiers with new imaging examinations as well as difficult and potentially dangerous interventional techniques. Why does this not happen in cardiac diagnosis? Perhaps there are sufficient opportunities in other fields to satisfy the career aspirations of young radiologists. Perhaps cardiologists believe that their patients are too ill or their condition too unstable to be handled by radiologists. Perhaps radiologists are intimidated by cardiologists who maintain an elite speciality. Whatever the reasons, diagnostic radiologists cannot avoid the obvious fact that diagnostic imaging of the heart is not currently a mainstream radiological activity. Radiologists are fully trained doctors and should therefore be in a position to undertake clinical supervision of cardiac patients in just the same way as they care for other patients. A radiologica! qualification should not be an excuse for avoidance of clinical responsibilities. In truth there is more than enough work to do in most cardiac centres and a partisan approach to one's own speciality can only lead to the patient being used as the pawn in an interdisciplinary game. In the small number of centres where there is already a good relationship between cardiology and radiology, the approach has been beneficial to all. The cardiologists are pleased to have expert help, the radiologists are doing a valuable and rewarding job and the patients are better served. Cardiac radiologists in the U K have reminded their colleagues from time to time of the low profile of cardiac radiology. As a group they are able to give advice and recommendations on training, requirements for consultant staffing, selection and maintenance of cardiac imaging equipment and of course on the principles and
452
CLINICAL RADIOLOGY
practice of cardiac radiology itself. All hospitals with specialist cardiac services should have an appropriate consultant committment to the cardiac radiology service. All radiology training departments should ensure that trainees at all levels are given suitable training in cardiac diagnosis as a matter of course. Why should one organ be saved for post Fellowship level? In the USA where many of the early developments in cardiac radiology took place, there are now virtually no active cardiac radiologists. Financial pressures have no doubt played a great part in this decline and though these pressures exist also in the U K they are of a lesser order. More important has been the neglect of cardiac radiology in favour of other techniques which are not subject to competition from other specialities. Without urgent action the same loss of an integral part of our speciality will happen by default in this country.
There is a small but increasing number of radiologists skilled in cardiac work who are well qualified and willing to improve the training of the very many able young clinicians who compete fiercely to enter radiology training programmes. The radiology profession should therefore encourage cardiac radiology training for the general radiologist as well as the specialist radiologist. All radiology training programmes should include a proper period of attachment to a cardiac service and ultimately all radiology departments in specialist cardiac centres should have an appropriate recognised consultant cornmittment to the cardiac work. Not only should we ensure the survival of cardiac radiology as a sub-speciality but in this exciting age of rapidly developing technology it should be seen as a challenging and rewarding option for young radiologists.
What is the Future for Cardiac Radiology? p. W I L D E -
Bristol Royal Infirmary, Bristol BS2 8 H W
The present position of cardiac radiology in Britain today reflects major inconsistencies between the needs of patients with cardiac disease and the response of diagnostic radiologists to those needs. Cardiac disease is the major cause of death and morbidity in this country today, affecting patients of all ages from the fetus to the elderly; in spite of extensive research and efforts at prevention, its overall incidence is changing very little. Recent reports suggest a reduction in the high incidence of coronary heart disease over the last 10 to 15 years but it is hard to tell if this is significant or if it will be sustained. The incidence of congenital heart disease has not changed for many decades and the increase in degenerative heart disease in our expanding elderly population has replaced rheumatic heart disease as the major cause of adult valvular dysfunction. In the last 30 years medical and surgical treatments for cardiac disease have dramatically improved and they have enhanced the lifestyle of huge numbers of patients whose symptoms have been reduced or abolished. There is current speculation that the early signs of decreasing coronary mortality may be due at least in part to life prolonging treatments. Such effective treatments must be preceded by accurate diagnosis, a large part of which depends on cardiac imaging techniques. Coronary arteriography is an essential precursor to coronary surgery and it is probable that it is now the most common invasive imaging technique with approximately 30-40000 coronary arteriograms being performed annually in the UK. Echocardiography has revolutionised the practice of cardiology; not only can structural abnormalities of valves and chambers be clearly and noninvasively delineated, but haemodynamic parameters such as valve pressure gradients and pulmonary artery pressures can be determined accurately. Computed tomography is commonly used to diagnose aortic root dissection and is the examination of choice for masses and turnouts adjacent to the heart. Isotope scanning gives important functional insights into the heart and now magnetic resonance imaging combines functional and anatomical cardiac assessment is a new and exciting way. Digital angiography is becoming well adapted to the assessment of the moving heart and can simplify the assessment ofventricular function. In some centres digital cardiac studies have taken over the angiographic diagnosis of congenital heart disease. The plain chest radiograph must not be forgotten in this list of complex imaging modalities. This simple examination often allows accurate diagnosis of specific cardiac pathology and still forms the basis for many decisions in the management of cardiac patients, showing changing appearances of heart and lungs as disease or treatment progresses. Unfortunately, apart from interpreting chest radiographs most radiologists play a small part in this large and expanding field of medical technology. The overwhelming majority of coronary arteriograms are performed by cardiologists in spite of this being an investigation requiring expert knowledge of radiographic imaging
techniques, radiation hazards, and interpretation skills needed during as well as after the examination. Skilled echocardiography combines an understanding of diagnostic ultrasound, cardiac function and pathology with practical experience. Radiologists are fortunate to have a formal training period in which it can be taught; cardiologists by contrast usually have no such opportunity and have to pick up the skills 'on the job'. In spite of this most echocardiograms are performed by cardiologists or cardiological technicians. In addition to a heavy clinical workload with its ever increasing demands, there are numerous skills to be acquired by clinical cardiologists. These include resting and stress electrocardiography, 24 hour monitoring, electrophysiology, pacemaking and of course the gamut of cardiac drug therapies. Additionally many clinical cardiologists attempt to be fully conversant with the complete range of cardiac imaging techniques. The limitations in junior medical staff manpower as a consequence of government policy in 'Achieving a Balance' have increased this problem and most cardiology departments are now hard pressed to keep up with the clinical workload. This would be the case in all clinical disciplines if they performed their own diagnostic imaging! In every other branch of medicine modern radiologists are happy to advertise new technological skills to their colleagues and push back frontiers with new imaging examinations as well as difficult and potentially dangerous interventional techniques. Why does this not happen in cardiac diagnosis? Perhaps there are sufficient opportunities in other fields to satisfy the career aspirations of young radiologists. Perhaps cardiologists believe that their patients are too ill or their condition too unstable to be handled by radiologists. Perhaps radiologists are intimidated by cardiologists who maintain an elite speciality. Whatever the reasons, diagnostic radiologists cannot avoid the obvious fact that diagnostic imaging of the heart is not currently a mainstream radiological activity. Radiologists are fully trained doctors and should therefore be in a position to undertake clinical supervision of cardiac patients in just the same way as they care for other patients. A radiologica! qualification should not be an excuse for avoidance of clinical responsibilities. In truth there is more than enough work to do in most cardiac centres and a partisan approach to one's own speciality can only lead to the patient being used as the pawn in an interdisciplinary game. In the small number of centres where there is already a good relationship between cardiology and radiology, the approach has been beneficial to all. The cardiologists are pleased to have expert help, the radiologists are doing a valuable and rewarding job and the patients are better served. Cardiac radiologists in the U K have reminded their colleagues from time to time of the low profile of cardiac radiology. As a group they are able to give advice and recommendations on training, requirements for consultant staffing, selection and maintenance of cardiac imaging equipment and of course on the principles and
452
CLINICAL RADIOLOGY
practice of cardiac radiology itself. All hospitals with specialist cardiac services should have an appropriate consultant committment to the cardiac radiology service. All radiology training departments should ensure that trainees at all levels are given suitable training in cardiac diagnosis as a matter of course. Why should one organ be saved for post Fellowship level? In the USA where many of the early developments in cardiac radiology took place, there are now virtually no active cardiac radiologists. Financial pressures have no doubt played a great part in this decline and though these pressures exist also in the U K they are of a lesser order. More important has been the neglect of cardiac radiology in favour of other techniques which are not subject to competition from other specialities. Without urgent action the same loss of an integral part of our speciality will happen by default in this country.
There is a small but increasing number of radiologists skilled in cardiac work who are well qualified and willing to improve the training of the very many able young clinicians who compete fiercely to enter radiology training programmes. The radiology profession should therefore encourage cardiac radiology training for the general radiologist as well as the specialist radiologist. All radiology training programmes should include a proper period of attachment to a cardiac service and ultimately all radiology departments in specialist cardiac centres should have an appropriate recognised consultant cornmittment to the cardiac work. Not only should we ensure the survival of cardiac radiology as a sub-speciality but in this exciting age of rapidly developing technology it should be seen as a challenging and rewarding option for young radiologists.