Radiology and the Heart

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Cardiology and radiology: Are they two specialties working in tandem for optimal patient care or two opposing armies in a turf battle? The answer, of course, is complicated, and can’t be approached without an acknowledgement of the ground already ceded to cardiology.

In today’s hospitals, cardiac ultrasound, cardiac catheterization, and (in many cases) nuclear cardiology are all the purview of the cardiologist. Newer, noninvasive techniques such as CT angiography (CTA) and MR angiography provide a fresh proving ground for each of the two specialties to demonstrate their unique worth—while they are under pressure to care for patients more efficiently and cost effectively than ever.

As cardiologist Guy Weigold, MD, director of cardiac CT at Washington Hospital Center, Washington, DC, points out, “You take an image of the heart, and put it in front of a cardiologist and a radiologist, and those two people are going to see very different things. The cardiologist is going to see the disease and innately understand the clinical implications, but would have a hard time appreciating the subtleties of the artifacts. The radiologist, on the other hand, might have a better understanding of the artifacts and other issues related to image quality, but doesn’t innately understand the clinical implications.”

Models for collaboration between cardiology and radiology vary widely. At Washington Hospital Center, for instance, the bulk of cardiac imaging is handled by cardiologists, although cardiac CT and MRI are still shared. Cardiologists do an initial interpretation for disease, and radiologists perform a second interpretation with the intention of identifying any incidental findings and issuing necessary follow-up recommendations.

By contrast, at the University of Maryland Medical Center (UMMC) in Baltimore, radiologists still perform most cardiac imaging, according to Charles White, MD, chief of thoracic radiology. “We’re all the way on the side of the spectrum where radiology really does the bulk of the CT and MRI,” he says. “We do it all. We’re happy to have the cardiologists’ participation, but the issue has been that they are involved in so many other things that there hasn’t been anyone with the time or bandwidth to be heavily involved from their side. We value their clinical expertise, but the protocol, patient work-up, and decision making of the imaging piece are all performed within radiology.”

Natural Evolution

This model evolved, White says, from the fact that the radiology department at UMMC was an early developer of a strong cardiac MRI program. When cardiac CT became increasingly prevalent, it made sense for radiology to continue superintending its use.

“It was not much of a stretch for us to expand into cardiac CT,” White recalls. “A turf battle is more likely to occur when you have a vacuum—when there wasn’t a cardiac CT or MRI program before, it was new ground, and so it became a new negotiation. A lot depends on referral patterns and on whether the services and relationships that already exist are good.”

Ricardo Cury, MD, director of cardiac imaging at Baptist Hospital of Miami in Florida and of Baptist Cardiac and Vascular Institute, concurs. “Of our cardiac CT, 40% to 50% comes from the emergency department, and radiology already provides emergency-department work for CT imaging, so it makes sense for radiology to do cardiac CT for the emergency department as well,” he says.

He adds, “We also have a history, here at Baptist Hospital of Miami, of over 15 years of providing very good service for nuclear cardiology due to the efforts of Jack Ziffer, MD. That helped, over time, to maintain cardiac CT and cardiac MRI. Obviously, building that confidence from other clinicians is a process that takes time.”

James Earls, MD, a radiologist with Fairfax Radiological Consultants in Virginia, notes that in the case of his group, its primary hospital client tasked it with developing a program that would be shared between cardiology and radiology. “When we went out and purchased the cardiac CT scanner for the hospital, it said we would share it equally,” he says. “Because we have an established outpatient cardiac CT program (we’ve been doing it since 2002), the cardiologists had a lot of respect for the radiologists’ experience doing it even before we opened the joint program at the hospital.”

He adds, however, that Virginia happens to be a very restrictive state when it comes to issuing certificates