Misinformation To Patients Concerning Radiation Exposures From

Myocardial Perfusion Imaging; And

Medical Radiation From Any Test Or Treatment Cannot Be Compared

To Natural Radiation.

Gerald Tobias DVM

A nurse answering my call to a cardiology office said: Ive been here

for 30 years, and the exposure for a heart nuclear scan is equal to 1 chest
X-ray (CXR). You can find this claim and other incorrect information given
to patients about myocardial perfusion imaging (MPI). Patients are assured
the radiation doses are small, safe, and free of side effects. Radiation ex-
posures are underestimated when described as equal to effective dose
levels, and inappropriately compared to natural radiation. Tumorigenic po-
tentials are often not mentioned, and nuclear scans are excessively re-
peated. Major hospitals, university medical centers, and many journal arti-
cles are guilty of many of these shortcomings. This lack of truthful disclo-
sure is putting patients at risk.

Anywhere in the United States, on websites belonging to major hospi-

tals and large cardiology offices, you can often find the radiation dose of a
MPI scan described as small or low or safe, or having no side effects. If the
radiation dose from a MPI scan is called small or low, what would you call
the dose of a chest radiograph (0.02mSv) that is 3,000 times smaller, or the
dose of a dental bitewing (0.005 mSv) (an x-ray of the posterior teeth) that
is 12,000 times smaller? The public has an idea of what small or low is
 it describes an exposure that should be benign. The common descrip-
tion that all radiation doses below 100 mSv are to be considered low and
safe is outdated. An increased cancer risk has been documented in doses
as low as 10 (1) to 15 mSv (2).

Thallous Chloride Tl 201 imaged patients can give off gamma radia-

tion for an entire month,(a) and Technetium Tc 99m Sestamibi for days

post-imaging. This is one of their side effects. Such patients should avoid
contact with infants, children and pregnant women for the appropriate time
interval.

Many cardiology websites say that the radiation exposure of a MPI is

equal to 1 CXR. The radiation dose of a 1 day rest-stress protocol when us-

ing Technetium Tc99m Sestamibi is approximately 60mSv, (b) which equals

3000 +/- CXRs,(c) a misstatement of 300,000 percent. The 60mSv is the

weighted equivalent dose (3) to the most critical organ (the upper large in-
testine) when Technetium Tc99m Sestamibi is used. The critical organ(s)
such as the liver, gall bladder, kidney, or large intestines are exposed to the
most radiation because these organs concentrate the injected radioisotope,
usually during the process of excretion and/or due to the organs higher
susceptibility to ionizing radiation. These highest doses in the critical
organ(s) which vary, depending on the radiopharmaceutical used, correctly
predicts ionizing radiations tumorigenic risks to a patient (4).

Some cardiologists incorrectly tell patients that the radiation dose for
a MPI test is its effective dose, which for a 1 day rest-stress protocol using
Technetium Tc99m Sestamibi is 17 +/-mSv ( = 850 CXRs +/-). (5)(d) The

effective dose which is an average of all the weighted equivalent doses

(e) to all the bodys organs is irrelevant to a specific patient (6,7). Its

usefulness is for researchers to compare different drugs or techniques. For

example, one patient that had 1 MPI scan yearly for 10 years; his cumula-
tive effective dose was 170 mSv (17mSv x 10 scans). Using the weighted
equivalent dose to the critical organ (the upper large intestine), the cumula-
tive dose is 600 mSv (60mSv x 10 scans). The effective dose underesti-
mates the patients true radiation exposure and the potential for radiation-
induced cancer.

Many cardiologists fail to tell patients of any tumorigenic risks from

MPI, and that repeated MPI further increases this risk. The percent in-
crease in cancer after medical radiation is controversial. According to one
article (8), one MPI scan caused 10 additional cancers per 10,000 tests, or
0.001% increase, and with each repeated scan, the cancer rate doubles. If
a patient had 5 scans, the chances of cancer are 10 in 625, or 1.5%, and if
the patient had 10 scans, it increases to 10 in 20, or 50%. The patient de-
scribed above who had 10 MPI tests was never warned about any cancer
risks. He subsequently required one kidney removed due to neoplasia. All
medical radiation such as used in angiography, interventional cardiology,
and CT scans add to a patients cumulative radiation dose. Also, radia-
tion doses can be double or more than the listed dose due to many vari-
ables (9).
 Many scientific articles say medical radiation can be compared to one
or more years of natural radiation (as from radon, rocks, cosmic sources,
air travel, food, water, etc.) which exposes all life to 3 mSv +/- a year. This
comparison is wrong. Even a dental bitewing, with the radiation dose of
1/12,000 of a MPI, is not comparable to natural radiation. The comparisons
of medical radiation to natural radiation are likely used because the word
natural sounds unthreatening and appealing to patients and medical pro-
fessionals. In one second, natural radiation equals 0.0000001mSv (one 10-
millionth mSv). All life on earth has developed and done well over 3 12 bil-
lion years in the presence of natural radiations almost non-existent sec-
ond-by-second dose. Its the IV injection of a total of 40mCi of Technetium
Tc99m Sestamibi during the hour or two duration of the rest- stress test that
results in its radiation detriment. To make the 40mCi dose as safe as natur-
al radiation, the radiopharmaceutical would have to be given slowly and
continuously over 7,300 days (20 +/- year period).

*****
Summary: Regarding the radiation tests they provide, many cardiologists
fail to make full disclosure about the radiation doses and dangers to which
patients are exposed. The proper description for a MPI scan is that the

radiation exposure is a moderate dose, does have side-effects, and in mid-

dle to older-aged adults, results in a potentially very small increase of future
cancer. The risks for women are higher, and much higher in children (2).
a. An individual that received a Thallous Chloride Tl 201 MPI scan 30 days
earlier set off securitys Geiger counter when entering a tennis stadium.

b. One-Day Rest-Stress protocol (Lantheus package insert for Cardiolite)

Table 1.0, using 1/3rd dose in the rest portion (10mCi). The radiation ab-
sorbed dose to the upper large intestines is about 1/3rd of 55.5mGy or 18.5
mSv. This would be more clear if the radiation absorbed dose was labeled
the weighted equivalent dose and the units in mSv. Using 30mCi in the
stress portion, the weighted equivalent dose to the upper large intestinal
tract is 44.4mSv. The total is 60.0 +/- mSv.

c. 50 posterior/anterior chest x-rays each 0.02 mSv = 1 mSv. 60mSv x 50 =

3000 CXRs. A stress- only test = 2000 +/- CXRs and a 2 day rest-stress
test = 4000 +/- CXRs.

d. Calculation of Effective doses from reference #5. p. 535, Table 1. Using

Technetium Tc99m Sestamibi/ rest test / male = 1.33E-02 mSv/MBq x
370MBq = 4.9 mSv (Using 1/3 0f 1110.MBq or 10mCi). Stress test =
1.07E-02 mSv/MBq x 1110. MBq (30 mCi) = 11.9 mSv. Effective dose total
is 17 +/- mSv.

e. The weighted equivalent dose is derived initially from the absorbed

dose. Absorbed dose and equivalent dose are equal during diagnostic radi-
ation tests which only use x-rays or gamma rays. Equivalent dose x a tis-
sue weighting factor ( corrects for the differing susceptibilities of tissues to
radiation injury) = the weighted equivalent dose for each tissue.
REFERENCE NOTES

1. Eisenberg MJ, Afilalo J, Lawler PR, Abrahamowicz M, Richard H, Pi-

lote L. Cancer risk related to low-dose ionizing radiation from cardiac
imaging in patients after acute myocardial infarction. CMAJ-JAMC
2011; 183(4): 430-436

2. Picano E, Vano E, Semelka R, Regulla D. The American College of

Radiology white paper on radiation dose in medicine; deep impact on
the practice of cardiovascular imaging. Cardiovasc Ultrasound 2007;
5: 37.doi: 10.1186/1476-7120-5-37.

3. Einstein AJ, Moser KW, Thompson RC, Cerqueira MD, Henzlova MJ.
Contemporary Reviews in Cardiovascular Medicine. Radiation Dose
to Patients From Cardiac Diagnostic Imaging. CirculationAHA.
2007;116: 1290-1306

4. FDA: U.S. Food and Drug Administration; Radiation-Emitting Prod-

ucts and Procedures; Medical Imaging; Medical x-ray Imaging; Radia-
tion Quantities and Units.

5. Toohey RE, Stabin MG. Comparative analysis of dosimetry parame-

ters for nuclear medicine. Page 532. Oak Ridge Institute for Science
 and Education, P.O. Box 117, Oak Ridge, TN 37831

6. Brenner DJ, Effective Dose: A flawed concept that could and should
be replaced. Br J. of Radiol 2008; 81:521-523;.

7. Fahey F, Fisher F, Stabin M. Appropriate Use of effective Dose and

organ dose in Nuclear Medicine. JACR Nov 2012. (File 104)

8. Berrington de Gonzalez A, Kim KP, Smith-Bindman R, McAreavey D.

Myocardial perfusion scans: projected population cancer risks from
current levels of use in the United States. Circulation 2010; 122(23):
2403-10.

9. Stabin MG. Uncertainties in Internal Dose Calculations for Radio-

pharmaceuticals. J Nucl Med May 2008 vol. 49 no. 5 853-860