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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 4, July/August 2017
AFRICA
233
even in environments with significant resource constraints, as
all of the specified best practices can be implemented with no
additional cost, and in some cases, a cost reduction.
Changing demographics and increased socio-economic
development on the African continent are contributing to
a rise in chronic illness, especially cardiovascular disease.
17,18
Commensurate with this rise will be increased demand for
diagnostic imaging. Resource constraints and a lack of available
expertise have been cited as challenges to providing nuclear
cardiology procedures in Africa.
15,19
Furthermore, few nuclear
cardiology-capable centres exist in Africa, even compared to
developing nations elsewhere in the world; their equipment
is older, and practitioners perceive a high need for additional
training in a variety of nuclear medicine techniques.
16
The data presented here may reflect these challenges. For
example, the use of PET imaging among observed African
laboratories was quite low, likely owing to lack of access to
the relatively expensive scanners and/or radiopharmaceuticals,
which in many cases require on-site manufacture. Likewise, the
high use of stress-only imaging may be a result of careful use
of scarce radiopharmaceuticals and camera time on the part of
African nuclear medicine physicians. On the other hand, the lack
of nuclear cardiology infrastructure (and therefore opportunity
for training physicians and developing expertise) relative to other
regions in the world may have contributed to the development of
regional centres of excellence.
20
Despite the increasing prevalence of coronary artery disease
in Africa, which has accompanied westernisation, owing
to limitations in trained personnel and equipment, nuclear
cardiology capabilities presently exist in few African countries.
Even in those countries where there are MPI capabilities, there
are few laboratories. These are concentrated in regional referral
centres, many of which are university-based teaching hospitals
receiving technical assistance from IAEA. This assistance is
provided through the IAEA’s technical cooperation programme.
Under this programme, every year regional training courses
are organised on specific nuclear medicine topics, with a major
focus on nuclear cardiology. Participants from all over the African
region, financially supported by the technical cooperation
programme, gather in the host centres to attend lectures and
practical sessions given by international experts. Furthermore,
the IAEA provides financial support to fellowships that may
last two to three months or up to years, to train future leaders
in the field and develop regional centres of excellence. For many
centres, the programme also supports the purchase of equipment
and even SPECT cameras. The high rate of adherence to best
practices observed among African laboratories is consistent with
the concept of centres of excellence.
Limitations
Our study has some limitations. There is no comprehensive
list of laboratories performing nuclear cardiology procedures
in many countries, therefore it is not clear to what extent data
acquired in the INCAPS study represents typical MPI practice
around the world. Furthermore, the low number of participating
laboratories in Africa may further exacerbate this concern. One
could argue that the participation rate in Africa reflects the
relative lack of nuclear cardiology-capable laboratories on the
continent – such laboratories are known by the IAEA to exist in
only eight countries, six of which are represented in this study. It
is possible that those laboratories that did participate are more
engaged with the international radiation protection community,
and therefore patient ED and best-practice adherence data
presented here may represent the best-case scenario among
African laboratories. Unfortunately we could not determine
the response rate for participation, as the multiple mechanisms
used to contact laboratories contain some overlap. However our
study did manage to recruit 12 of 30 (40%) of the laboratories
performing MPI in Africa, identified by the IAEA database.
In addition, this study did not assess image quality or patient
outcomes. Therefore we cannot determine whether lower patient
ED and high uptake to the specified best practices indeed
translate to improved patient care. Finally, the fact that two
laboratories that adhered to all eight best practices showed overall
higher ED suggests that our metrics may not be sensitive to the
African MPI environment. Future research should examine how
to optimise dose-reduction best practices to the local context.
Conclusion
Our study of nuclear cardiology practice reveals that African
laboratories performed better than the rest of the world with
regard to best-practice adherence to optimise patient radiation
dose. However wide variation in practice still exists and greater
uptake of stress-only imaging, use of camera-based dose-
reduction technologies, and optimised dosing protocols may
provide additional opportunity to further reduce radiation
exposure from MPI in Africa, often at no extra cost to care.
The authors gratefully acknowledge funding from the International Atomic
Energy Agency, the Margaret Q Landenberger Research Foundation (in
memory of Prof A Donny Strosberg) and the Irving Scholars Program. We
affirm not having entered into an agreement with the funders that may have
limited our ability to complete the research as planned, and indicate that we
have had full control of all primary data. We are grateful to the INCAPS
Investigators Group members* and their institutions for efforts in collecting
the data, and to the cooperating professional societies, including the American
Society of Nuclear Cardiology, the Asian Regional Cooperative Council
for Nuclear Medicine, Australian and New Zealand Society of Nuclear
Medicine, British Nuclear Medicine Society/British Nuclear Cardiology
Society, Comissão Nacional de Energia Nuclear, European Association of
Nuclear Medicine, European Council of Nuclear Cardiology, IAEA and the
Intersocietal Accreditation Commission. Dr Einstein has received research
grants for other investigator-initiated studies from GE Healthcare, Philips
Healthcare, Spectrum Dynamics and Toshiba America Medical Systems. The
other co-authors have no disclosures.
*Members of the INCAPS investigators group
Executive committee:
AJ Einstein (chair), TNB Pascual (IAEA project lead),
D Paez (IAEA section head), M Dondi (IAEA section head); (alphabetically)
N Better, SE Bouyoucef, G Karthikeyan, R Kashyap, V Lele, VPC Magboo,
JJ Mahmarian, M Mercuri, F. Mut, M.M. Rehani, J.V. Vitola.
Regional coordinators:
(alphabetically): E Alexánderson (Latin America),
A Allam (Africa/Middle East), MH Al-Mallah (Middle East), N Better
(Oceania), SE Bouyoucef (Africa), H Bom (East Asia), A Flotats (Europe),
S Jerome (United States), PA Kaufmann (Europe), V Lele (South Asia),
O Luxenburg (Israel), J Mahmarian (North America), LJ Shaw (North
America), SR Underwood (United Kingdom), J Vitola (Latin America).