COCATS Guidelines for Level 2 Training in Nuclear Cardiology

Overview of Nuclear Cardiology Training
Training in nuclear cardiology at all levels should provide an understanding of the indications for specific nuclear cardiology tests, the safe use of radionuclides, basics of instrumentation and image processing, methods of quality control, image interpretation, integration of risk factors, clinical symptoms and stress testing and the appropriate application of the resultant diagnostic information for clinical management. Training in nuclear cardiology is best acquired in Accreditation Council for Graduate Medical Education (ACGME) approved training programs in cardiology, nuclear medicine or radiology. An exception to this ACGME requirement is the didactic and laboratory training in radiation safety and radioisotope handling that may be provided by qualified physicians/scientists in a non-ACGME program when such a program is not available as part of the clinical ACGME training program. For laboratories that provide training to cardiology fellows, accreditation by the Intersocietal Commission for the Accreditation of Nuclear Laboratories (ICANL) is also recommended.

Didactic, clinical case experience and hands-on training hours require documentation in a logbook¹ and having the trainee's name appear on the clinical report or having some other specific record. The hours need to be monitored and verified by the nuclear cardiology training preceptor.

Specialized Training - Level 2 (Minimum of 4 Months)
Fellows who wish to practice the specialty of nuclear cardiology are required to have at least 4 months of training. This includes a minimum of 700 hours of radiation safety training in nuclear cardiology. There needs to be didactic, clinical study interpretation, and hands-on involvement in clinical cases. In training programs with a high volume of procedures, clinical experience may be acquired in as short a period as 4 months. In programs with a lower volume of procedures, a total of 6 months of clinical experience will be necessary to achieve Level 2 competency. The additional training required of Level 2 trainees is to enhance clinical skills, knowledge, and hands-on experience in radiation safety and to qualify them to become authorized users of radioactive materials in accordance with the regulations of the Nuclear Regulatory Commission (NRC) and/or the Agreement States.

Didactic Program
Lectures and self-study. The didactic training should include in-depth details of all aspects of the procedures listed in Table 1 (see below). This program may be scheduled over a 12- to 24-month period concurrent and integrated with other fellowship assignments.

Radiation Safety. Classroom and laboratory training needs to include extensive review of radiation physics and instrumentation, radiation protection, mathematics pertaining to the use and measurement of radioactivity, chemistry of byproduct material for medical use, radiation biology, the effects of ionizing radiation and radiopharmaceuticals. There should be a thorough review of regulations dealing with radiation safety for the use of radiopharmaceuticals and ionizing radiation. This experience should total a minimum of 80 hours and be clearly documented.

Interpretation of Clinical Cases
Fellows should participate in the interpretation of all nuclear cardiology imaging data for the 4-6 month training period. It is imperative that the fellows have experience in correlating catheterization or CT angiographic data with radionuclide-derived data in a minimum of 30 patients. A teaching conference in which the fellow presents the clinical material and nuclear cardiology results is an appropriate forum for such an experience. A total of 300 cases should be interpreted under preceptor supervision, from direct patient studies.

Hands-on Experience
Clinical cases. Fellows acquiring Level 2 training should have hands-on supervised experience in a minimum of 35 patients: 25 patients with myocardial perfusion imaging and 10 patients with radionuclide angiography. Such experience should include pretest patient evaluation, radiopharmaceutical preparation (including experience with relevant radionuclide generators and CT systems), performance of studies with and without attenuation correction, administration of the dosage, calibration and setup of the gamma camera and CT system, setup of the imaging computer, processing the data for display, interpretation of the studies and generating clinical reports.

Radiation safety work experience. This experience should total 620 hours and be acquired continuously during training in the clinical environment where radioactive materials are being used and under the supervision of an authorized user who meets the NRC requirements of Part 35.290 or Part 35.290(c)(ii)(G) and 35.390 or the equivalent Agreement State requirements, and must include:

a) Ordering, receiving and unpacking radioactive materials safely and performing the related radiation surveys;

b) Performing quality control procedures on instruments used to determine the activity of dosages and performing checks for proper operation of survey meters;

c) Calculating, measuring and safely preparing patient or human research subject dosages;

d) Using administrative controls to prevent a medical event involving the use of unsealed byproduct material;

e) Using procedures to safely contain spilled radioactive material and using proper decontamination procedures;

f) Administering dosages of radioactive material to patients or human research subjects; and

g) Eluting generator systems appropriate for preparation of radioactive drugs for imaging and localization studies, measuring and testing the eluate for radionuclide purity, and processing the eluate with reagent kits to prepare labeled radioactive drugs.

Additional experience
The training program for Level 2 training must also provide experience in computer methods for analysis. This should include perfusion and functional data derived from thallium or technetium agents and ejection fraction and regional wall motion measurements from radionuclide angiographic studies.

¹ Note: These logbooks are not to be submitted with the CBNC application.

1) Standard nuclear cardiology procedures

a) Myocardial perfusion imaging

i) SPECT with technetium-99m agents and/or thallium-201, with or without attenuation correction
ii) PET with rubidium-82 and/or nitrogen-13 ammonia
iii) Planar with technetium-99m agents and/or thallium-201
iv) ECG gating of perfusion images for assessment of global and regional ventricular function
v) Imaging protocols
vi) Stress protocols

1) Exercise stress
2) Pharmacologic stress

vi) Viability assessment including reinjection and delayed imaging of thallium-201 and/or metabolic imaging where available

b) Equilibrium radionuclide angiography and/or "first-pass" radionuclide angiography at rest
c) Qualitative and quantitative methods of image display and analysis

a) Combined myocardial perfusion imaging with cardiac CT for attenuation correction or anatomic localization
b) Equilibrium radionuclide angiography and/or "first-pass" radionuclide angiography during exercise or pharmacologic stress
c) Metabolic imaging using single photon and/or positron emitting radionuclides
d) Myocardial infarct imaging
e) Cardiac shunt studies

To receive a copy of the complete COCATS Guidelines for Training in Nuclear Cardiology, visit the American Society of Nuclear Cardiology Website: www.asnc.org.