
==== Front
Eur Radiol
Eur Radiol
European Radiology
0938-7994
1432-1084
Springer Berlin Heidelberg Berlin/Heidelberg

38683386
10741
10.1007/s00330-024-10741-4
Commentary
Competence and contributions of radiologists to cardiac CT and MR imaging across Europe
http://orcid.org/0000-0002-4402-2733
Dewey Marc Marc.dewey@charite.de

12345
1 grid.6363.0 0000 0001 2218 4662 Department of Radiology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
2 https://ror.org/0493xsw21 grid.484013.a Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
3 Berlin University Alliance, Berlin, Germany
4 grid.452396.f 0000 0004 5937 5237 DZHK (German Centre for Cardiovascular Research) partner site Berlin, Berlin, Germany
5 https://ror.org/01mmady97 grid.418209.6 0000 0001 0000 0404 Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
29 4 2024
29 4 2024
2024
34 10 65786580
19 3 2024
19 3 2024
20 3 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by/4.0/ Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
issue-copyright-statement© European Society of Radiology 2024
==== Body
pmcCardiovascular diseases remain the leading cause of mortality worldwide [1], emphasizing the crucial role of cardiovascular imaging modalities such as cardiac computed tomography (CT) and magnetic resonance (MR) imaging [2, 3]. Radiologists play a pivotal role in the accurate interpretation of these imaging studies, thereby influencing patient management and outcomes [4–13]. A large-scale analysis from the European Society of Cardiovascular Radiology (ESCR) registry addressed the status of radiologist competence in cardiac imaging across Europe and emphasized the need for standardization and collaboration to ensure optimal patient care [14].

Main findings of the analysis of the ESCR registry analysis

Significant increase in cardiac CT and MR examinations

Between 2011 and 2022, there was a notable surge in both cardiac CT and MR examinations across Europe, with a 4.5-fold increase in CT examinations and a 3.8-fold increase in MR examinations. This substantial rise underscores the growing importance of these imaging modalities in cardiovascular disease management and highlights the increasing demand for their utilization in clinical practice.

Evolution of clinical indications

The data reveal the following main clinical indications for cardiac CT and MR imaging. Suspected coronary artery disease (CAD) emerged as the predominant indication (59%) for cardiac CT, followed by transcatheter aortic valve replacement planning (21%). Interestingly, there was a notable increase in the number of patients with intermediate pretest probability undergoing CT for suspected CAD from 61% in 2012 to 82% in 2022, indicating a further increase in appropriate clinical decision-making. For cardiac MR, suspected myocarditis (26%), CAD (21%), and suspected cardiomyopathy (19%) were the main indications, reflecting the diverse diagnostic capabilities of this imaging modality in assessing myocardial inflammation, ischemia, and structural abnormalities.

Role of radiologists in reporting

The majority of CT and MR examinations were reported by radiologists (76% and 71%, respectively), underscoring their central role in the interpretation and diagnosis of cardiac imaging studies. However, a notable proportion of examinations were also reported in consensus with non-radiologists (19% and 27%, respectively), highlighting the importance of interdisciplinary collaboration in cardiac imaging. A small minority of CT and MR examinations (5% and 2%, respectively) were reported by non-radiological specialties or through separate readings of radiologists and non-radiologists.

How do these findings fit into the current landscape?

The field of cardiac imaging has witnessed rapid advancements in technology and techniques [15–17], enabling more accurate diagnosis and characterization of cardiovascular diseases. Cardiac CT and MR imaging have become indispensable tools in the evaluation of various cardiovascular and cardiothoracic conditions, including CAD, inflammation, myocardial ischemia, and cardiomyopathies. However, the interpretation of these imaging studies requires specialized knowledge and expertize, particularly in recognizing subtle anatomical and pathological findings and optimal use of novel technologies.

What are the remaining key opportunities?

An immense work has been done primarily by the European Society of Radiology (ESR) and the ESCR (in collaboration with national societies) with regard to further increasing the competence of radiologists in cardiac and cardiothoracic CT and MR imaging. Apart from the major congresses of the ESR and ESCR, these include initiatives to start education at the undergraduate level with the ESR ebook for undergraduate education with a dedicated chapter on Cardiac imaging [18], harmonizing radiology training through the European Training Curricula for general Radiology and subspecialisation training [19], the plethora of resources offered through the ESR Premium Education Package [20], the subspecialty diploma of the European Board of Cardiovascular Radiology (EBCR) [21], and availability of dedicated cardiovascular imaging fellowships through the European School of Radiology (ESOR) [22]. Great additional effort should be undertaken to further standardize protocols, implement artificial intelligence solutions, and promote consistent reporting [23, 24] through hands-on cardiac imaging courses.

Addressing these opportunities fully will benefit from multifaceted approaches involving the interdisciplinary collaboration of ESR and ESCR and other stakeholders, among them healthcare institutions, other professional societies, and regulatory bodies on the European and national levels. In addition, efforts should be made to establish additional clinical practice guidelines about cardiac MR [8] and CT [25] for image acquisition, interpretation, and reporting, thereby promoting high-quality consistency in clinical practice.

Furthermore, fostering collaboration among radiologists, general practitioners, cardiologists, and cardiac surgeons [10] is essential for enhancing interdisciplinary communication and facilitating optimal patient care. By continuing to establish multidisciplinary quantitative cardiovascular imaging meetings, further clinical and technical consensus publications will result [18, 19, 26] that will ultimately improve diagnostic performance, resource utilization, and patient outcomes.

What about sharing data from this analysis?

Importantly, the ESCR registry raw data underlying the original published article [14] is available upon request using office@escr.org for data sharing and exchange. It would be pivotal if the original source data underlying analyses such as the exciting previous analysis were more often shared with other researchers using data-sharing platforms such EUCAIM (www.eucaim.org) funded by the European Commission and/or the GUIDE-IT platform funded by German Research Foundation (DFG) (www.guide-it.org). This will ensure sustainable access to pivotal underlying information for the entire radiology community.

What are the conclusions that can be drawn from this analysis?

The competence and involvement of radiologists in cardiac CT and MR imaging play a critical role in the accurate diagnosis and management of cardiovascular diseases. Radiologists are central in the provision of cardiovascular imaging services and high-quality medical care in cardiovascular medicine. Suspected CAD and suspected myocarditis are the most common indications for cardiac CT and MR, respectively. The data from the ESCR registry also show a relevant increase by approximately a factor of four in cardiac CT and MR examinations in the last decade. Radiologists actively engaged in cardiovascular imaging play a central role in providing quantitative imaging findings as the basis for evidence-based recommendations for personalized optimal medical therapy and/or invasive treatment.

I would like to wholeheartedly congratulate the authors from the pivotal ESCR registry on providing important evidence using real-life data from Europe about the best use of cardiovascular imaging. We look very much forward to future analyses providing additional insights into the potential to further improve cardiovascular imaging and care.

Acknowledgements

This editorial was in part written based on prompts to Chat GPT, adhering to the editorial policy.

Funding

Open Access funding enabled and organized by Projekt DEAL.

Compliance with ethical standards

Guarantor

The scientific guarantor of this publication is Marc Dewey.

Conflict of interest

The author of this manuscript declares no relationships with any companies, whose products or services may be related to the subject matter of the article. Marc Dewey is Guest Editor of the ESR Essentials series and chairperson of the ESR Publications Committee.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was not required.

Ethical approval

Institutional Review Board approval was not required.

Study subjects or cohorts overlap

Not applicable.

Methodology

Commentary

This comment refers to the article available at 10.1007/s00330-024-10644-4.

Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
==== Refs
References

1. World Health Organization (WHO) (2019) Available via https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates. Accessed 19 March 2024
2. Dewey M (2014) Cardiac CT. Springer, Heidelberg
3. Higgins CB, de Roos A (2013) MRI and CT of the Cardiovascular System, 3rd edn. Wolters Kluwer
4. investigators S-H CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial Lancet 2015 385 2383 2391 10.1016/S0140-6736(15)60291-4 25788230
investigators S-H (2015) CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial. Lancet 385:2383–239125788230 10.1016/S0140-6736(15)60291-4
5. SCOT-HEART InvestigatorsNewby DE Adamson PD Coronary CT angiography and 5-year risk of myocardial infarction N Engl J Med 2018 379 924 933 10.1056/NEJMoa1805971 30145934
investigators S-H, Newby DE, Adamson PD et al (2018) Coronary CT angiography and 5-year risk of myocardial infarction. N Engl J Med 379:924–93330145934 10.1056/NEJMoa1805971
6. DISCHARGE Trial GroupKofoed K Bosserdt M Comparative effectiveness of initial computed tomography and invasive coronary angiography in women and men with stable chest pain and suspected coronary artery disease: multicentre randomised trial BMJ 2022 379 e071133 36261169
DISCHARGE Trial Group, Kofoed K, Bosserdt M et al (2022) Comparative effectiveness of initial computed tomography and invasive coronary angiography in women and men with stable chest pain and suspected coronary artery disease: multicentre randomised trial. BMJ 379:e07113336261169
7. DISCHARGE Trial GroupMaurovich-Horvat P Bosserdt M CT or invasive coronary angiography for stable chest pain N Engl J Med 2022 386 1591 1602 10.1056/NEJMoa2200963 35240010
DISCHARGE Trial Group, Maurovich-Horvat P, Bosserdt M et al (2022) CT or invasive coronary angiography for stable chest pain. N Engl J Med 386:1591–160235240010 10.1056/NEJMoa2200963
8. Emrich T, Wintersperger BJ, Greco FD et al (2024) ESR essentials: ten steps to cardiac MR-practice recommendations by ESCR. Eur Radiol. 10.1007/s00330-024-10605-x
9. Foldyna B Uhlig J Gohmann R Quality and safety of coronary computed tomography angiography at academic and non-academic sites: insights from a large European registry (ESCR MR/CT Registry) Eur Radiol 2022 32 5246 5255 10.1007/s00330-022-08639-0 35267087
Foldyna B, Uhlig J, Gohmann R et al (2022) Quality and safety of coronary computed tomography angiography at academic and non-academic sites: insights from a large European registry (ESCR MR/CT Registry). Eur Radiol 32:5246–525535267087 10.1007/s00330-022-08639-0
10. Dewey M Henriques JPS Kirov H Vliegenthart R ESR bridges: CT builds bridges in coronary artery disease Eur Radiol 2024 34 732 735 10.1007/s00330-023-10485-7 38291257
Dewey M, Henriques JPS, Kirov H, Vliegenthart R (2024) ESR bridges: CT builds bridges in coronary artery disease. Eur Radiol 34:732–73538291257 10.1007/s00330-023-10485-7
11. Gatti M Liguori C Muscogiuri G Challenges and opportunities to delivering cardiac imaging training: a national survey by the Italian college of cardiac radiology Insights Imaging 2021 12 136 10.1186/s13244-021-01076-5 34570297
Gatti M, Liguori C, Muscogiuri G et al (2021) Challenges and opportunities to delivering cardiac imaging training: a national survey by the Italian college of cardiac radiology. Insights Imaging 12:13634570297 10.1186/s13244-021-01076-5
12. Langenbach MC Sandstede J Sieren MM German Radiological Society and the Professional Association of German radiologists position paper on coronary computed tomography: clinical evidence and quality of patient care in chronic coronary syndrome Rofo 2023 195 115 134 10.1055/a-1973-9687 36634682
Langenbach MC, Sandstede J, Sieren MM et al (2023) German Radiological Society and the Professional Association of German radiologists position paper on coronary computed tomography: clinical evidence and quality of patient care in chronic coronary syndrome. Rofo 195:115–13436634682 10.1055/a-1973-9687
13. Sieren MM Maintz D Gutberlet M Current status of cardiovascular imaging in Germany: structured data from the national certification program, ESCR registry, and survey among radiologists Rofo 2022 194 181 191 10.1055/a-1554-9236 34384112
Sieren MM, Maintz D, Gutberlet M et al (2022) Current status of cardiovascular imaging in Germany: structured data from the national certification program, ESCR registry, and survey among radiologists. Rofo 194:181–19134384112 10.1055/a-1554-9236
14. Catapano F, Moser LJ, Francone M et al (2024) Competence of radiologists in cardiac CT and MR imaging in Europe: insights from the ESCR Registry. Eur Radiol. 10.1007/s00330-024-10644-4
15. Wolf EV Muller L Schoepf UJ Photon-counting detector CT-based virtual monoenergetic reconstructions: repeatability and reproducibility of radiomics features of an organic phantom and human myocardium Eur Radiol Exp 2023 7 59 10.1186/s41747-023-00371-8 37875769
Wolf EV, Muller L, Schoepf UJ et al (2023) Photon-counting detector CT-based virtual monoenergetic reconstructions: repeatability and reproducibility of radiomics features of an organic phantom and human myocardium. Eur Radiol Exp 7:5937875769 10.1186/s41747-023-00371-8
16. Klarenberg H Gosselink M Coolen BF A 72-channel receive array coil allows whole-heart cine MRI in two breath holds Eur Radiol Exp 2022 6 54 10.1186/s41747-022-00305-w 36316525
Klarenberg H, Gosselink M, Coolen BF et al (2022) A 72-channel receive array coil allows whole-heart cine MRI in two breath holds. Eur Radiol Exp 6:5436316525 10.1186/s41747-022-00305-w
17. Cundari G Galea N Mergen V Alkadhi H Eberhard M Myocardial extracellular volume quantification with computed tomography-current status and future outlook Insights Imaging 2023 14 156 10.1186/s13244-023-01506-6 37749293
Cundari G, Galea N, Mergen V, Alkadhi H, Eberhard M (2023) Myocardial extracellular volume quantification with computed tomography-current status and future outlook. Insights Imaging 14:15637749293 10.1186/s13244-023-01506-6
18. European Society of Radiology, Catalano C, Galea N, Marchitelli L (2022) eBook for Undergraduate Education in Radiology: Cardiac Imaging. 10.26044/esr-undergraduate-ebook-06
19. European Training Curricullum for Radiology (2024) Available via https://www.myesr.org/education/training-curricula/
20. European Society of Radiology (ESR) (2024) Available via https://www.myesr.org/education/premium-education-package/ Accessed 19 March 2024
21. European Society of Cardiovascular Radiology (ESCR) (2024) Available via https://www.escr.org/diploma/ Accessed 19 March 2024
22. European School of Radiology (ESOR) (2024) Available via https://www.esor.org/training-exchange-programmes/recently-certified/visiting-scholarship-programme-europe/escr/ Accessed 19 March 2024
23. QCI Study GroupFollmer B Williams MC Roadmap on the use of artificial intelligence for imaging of vulnerable atherosclerotic plaque in coronary arteries Nat Rev Cardiol 2024 21 51 64 10.1038/s41569-023-00900-3 37464183
QCI Study Group, Follmer B, Williams MC et al (2024) Roadmap on the use of artificial intelligence for imaging of vulnerable atherosclerotic plaque in coronary arteries. Nat Rev Cardiol 21:51–6437464183 10.1038/s41569-023-00900-3
24. QCI Study Group, Mezquita AJV, Biavati F et al (2023) Clinical quantitative coronary artery stenosis and coronary atherosclerosis imaging: a consensus statement from the quantitative cardiovascular imaging study group. Nat Rev Cardiol. 10.1038/s41569-023-00880-4
25. Dewey M (2024) The ESR essentials for the medical imaging community. Eur Radiol. 10.1007/s00330-024-10588-9
26. Dewey M Siebes M Kachelriess M Clinical quantitative cardiac imaging for the assessment of myocardial ischaemia Nat Rev Cardiol 2020 17 427 450 10.1038/s41569-020-0341-8 32094693
Dewey M, Siebes M, Kachelriess M et al (2020) Clinical quantitative cardiac imaging for the assessment of myocardial ischaemia. Nat Rev Cardiol 17:427–45032094693 10.1038/s41569-020-0341-8
