Nuclear Cardiology is cardiac imaging with radiotracers and gamma cameras. Nuclear Cardiology provides important diagnostic and prognostic information for the evaluation of cardiac patients. Stress myocardial perfusion imaging is an important technique for the diagnosis and assessment of the extent of Coronary Artery Disease and provides useful prognostic information. Gated blood pool imaging permits evaluation of both left and right ventricular function and is widely used. Imaging infarct-avid radiotracer permits assessment of myocardial necrosis and viability.
Understanding of the principles of nuclear medicine, cardiac physiology, and pharmacology as well as stress testing is essential for the adequate performance and interpretation of Nuclear Cardiology studies.
Standards for training in adult Nuclear Cardiology have been developed by the Nuclear Cardiology Subcommittee of the Canadian Cardiovascular Committee on Standards and are similar to the recommendations of the American College of Cardiology and American Society of Nuclear Cardiology [Ref 1]. Training in Nuclear Cardiology is divided into three levels:
- Basic training (CCS level 1), consisting of a 2-month training period achieved by all cardiology residents during the 3-year Cardiology program.
- Advanced training (CCS level 2), consisting of an additional 6 months of training during the second or third year of the 3-year Cardiology program.
- Fellowship training (CCS level 3), consisting of an additional 12 consecutive months beyond the completion of the 3-year Cardiology program.
With advanced training (CCS level 2), individuals can interpret and perform Nuclear Cardiology studies in an established facility. The Fellowship training (CCS level 3) is required to independently operate a Nuclear Cardiology facility to train other physicians, and may serve as a stepping stone to an academic career in Nuclear Cardiology.
Cardiac Positron Emission Tomography (PET) is part of Nuclear Cardiology, but is not widely available and is technically different. Guidelines for specific training in Cardiac PET have been developed by the American College of Cardiology and American Society of Nuclear Cardiology [Ref 1]. Training in PET may be concurrent with training in conventional Nuclear Cardiology and may include aspects unique to PET. Training is divided into three levels:
- General training as 2 months during the 3-year Cardiology program
- Specialized training as an additional 4 to 6 months during the 3-year Cardiology training program
- Advanced training as a minimum 1-year Fellowship following a 3-year Cardiology program
Individuals completing Royal College of Physicians and Surgeons of Canada accredited training programs in Nuclear Medicine will also be qualified to interpret Nuclear Cardiology studies and to train other physicians in their interpretation. They may or may not be qualified to perform stress testing and interpret cardiograms, depending upon their training site. They may wish to undertake additional training to embark upon an academic career in Cardiac Nuclear Medicine or to acquire the skills to perform stress testing or Cardiac PET, or to acquire additional knowledge of the application of Nuclear Cardiology techniques in the assessment and management of patients with cardiac disease.
Candidates for the Nuclear Cardiology training program include residents who have completed a 3-year training program in Cardiology or who have completed Nuclear Medicine training. Individuals who have achieved basic (CCS level 1) and advanced (CCS level 2) training levels during their 3-year resident programs can proceed to level 3 Fellowship training and achieve level 3 training in Nuclear Cardiology in one year. However, individuals with only basic (CCS level 1) training and without advanced training (CCS level 2) will require a minimum of 18 months to achieve level 3 training in Nuclear Cardiology. Achieving level 3 training in both Nuclear Cardiology and PET will require 24 months in most cases for cardiology-trained candidates and 12 to 18 months for Nuclear Medicine trained candidates (as few institutions offer basic or advanced training in PET during the routine cardiology or nuclear medicine training programs).
The general objectives of this 12-month Fellowship training (CCS level 3) training program in Nuclear Cardiology are to provide sufficient experience and training for the trainee to independently operate a Nuclear Cardiology facility and train other physicians. For individuals without advanced training (CCS level 2), the additional objectives would be to provide sufficient training for the individual to interpret Nuclear Cardiology studies independently.
The training period will consist of an additional 12 consecutive months beyond the completion of a 3-year Cardiology training program for individuals having achieved basic (CCS level 1) and advanced (CCS level 2) training in Nuclear Cardiology as part of their Cardiology training program. For individuals without advanced (CCS Level 2) training in Nuclear Cardiology as part of their 3-year Cardiology training program, the training period will consist of 18 to 24 consecutive months. The training of nuclear medicine residents will be reviewed and an appropriate course of study defined.
At the end of the Fellowship Nuclear Cardiology training program, individuals will have:
- Radiopharmacy experience sufficient to run a Nuclear Cardiology facility
- Technical and theoretical understanding of the operation of Nuclear Medicine cameras and computer systems
- Knowledge of radiation protection and safety and regulatory aspects
- Ability to interpret stress planar and tomographic myocardial perfusion studies and gated blood pool studies from a broad patient mix
- Experience in performance and interpretation of exercise and pharmacologic stress tests
- Demonstration of teaching ability to technicians, resident trainees, and other staff
- Clinical appraisal of current Nuclear Cardiology research
- Participation in Nuclear Cardiology research
The trainee will be required to perform in their entirety 50 gated blood pool imaging studies, 50 exercise myocardial perfusion studies, and 50 pharmacologic stress perfusion studies, and interpret an additional 500 studies with clinical correlation.
Trainees with a Nuclear Medicine background will be considered to have completed the first 3 training items above. They will be expected to complete the additional following items:
- Observe a minimum of 50 coronary angiographic procedures with myocardial perfusion imaging correlation and participate in the conferencing of those cases.
- Have a basic knowledge of:
- coronary anatomy
- cardiac hemodynamics
- exercise physiology
- standard cardiovascular pharmacology
- rest and stress electrocardiography
- Complete the ACLS course
Specific training in Cardiac PET may be concurrent with training in conventional Nuclear Cardiology and will, in most cases, be part of an additional 24 consecutive months beyond the completion of a 3-year Cardiology training program or Nuclear Medicine training program.
- Knowledge of substrate metabolism in the normal and diseased heart
- Knowledge of PET tracers for perfusion, metabolism, and neuronal activity imaging
- Knowledge of radioisotope production and radiotracer synthesis
- Principles of tracer kinetics and their in vivo application for the non-invasive measurements of regional metabolic and functional processes
- Knowledge of physics of positron decay, imaging instrumentation specific to PET, quality control and handling of ultrashort-life radioisotopes, appropriate radiation protection, and safety and regulatory aspects.
The trainee will be required to perform in their entirety, 40 myocardial perfusion studies and 40 metabolic studies and interpret an additional 400 studies with clinical correlation.
- Institution - The trainee will work in Nuclear Cardiology at the University of Ottawa Heart Institute to obtain training in Nuclear Cardiology and in the Cardiac PET Unit, to obtain Cardiac PET training. The Heart Institute is a large tertiary care cardiac facility serving patients in Eastern Ontario and Western Quebec. The Heart Institute has in-patient and out-patient services, critical care and coronary care units, cardiac catheterization/angiographic facilities, a cardiac surgical program, and an active Emergency Room.
- Laboratory - The Nuclear Cardiology laboratory is located in the University of Ottawa Heart Institute. Over 5,000 patient examinations are performed in Nuclear Cardiology and exercise stress and pharmacologic stress myocardial perfusion studies as well as gated blood pool imaging for evaluation of ventricular function. The Cardiac PET Unit is located in the University of Ottawa Heart Institute Research Centre and carries out over 500 clinical and research PET patient studies per year.
- Staff - The physician staff for Nuclear Cardiology includes four full-time Nuclear Cardiologists. The Nuclear Cardiologists have Level 3 Fellowship training as defined by the Nuclear Cardiology Subcommittee of the Canadian Cardiovascular Committee on Standards and by the American College of Cardiology. Three of the Nuclear Cardiologists staff the Cardiac PET Unit. The Director of the Cardiac PET Unit has Level 3 training in PET as defined by the American College of Cardiology.
The Nuclear Cardiology Laboratory and the Cardiac PET Unit have a full complement of nuclear technologists, nursing staff, and a PET physicist.
Evaluation and Examination Process
- Assessment will be ongoing with the training supervisor and the laboratory staff physicians.
- Written and practical tests will occur every 3 months. The trainee will be interviewed every 3 months and advised of their progress in terms of results of the written and practical tests in the ongoing assessment. Criticisms and deficiencies will be noted.
- Upon completion of the 12-to-24-month program, there will be a final examination, consisting of a written and oral examination testing the knowledge of Nuclear Cardiology (and PET for PET trainees) and interpretation of Nuclear Cardiology (and PET for PET trainees) patient examinations.
- The trainee will be expected to initiate and develop a research protocol leading to data collection, analysis, abstract preparation, and manuscript submission during the Fellowship training program.
1. Ritchie JL, Gibbons RJ, Johnson LL, Maddahi J, Schelbert HR, Wackers FJ, Zaret BL: Task Force 5: Training in Nuclear Cardiology. J Am Coll Cardiol 1995:25(1);1-34.