February 25, 2026JAMA
Worldwide Radiation Dose in Coronary Artery Disease Diagnostic Imaging
Andrew J. EinsteinMichelle C. WilliamsJonathan Weir-McCallLeslee J. ShawGanesan KarthikeyanNathan BetterJoão V. VítolaRODRIGO JULIO CERCISharmila DorbalaSalah E. BouyoucefA D ChoiGianluca PontoneElgin ÖzkanLe YangLuca BremnerMichelle CastilloYosef A CohenEli MalkovskiyIsmaila AyoolaAnna VedutaDanylo YurystovskyiY PyndaMathew MercuriPeter KnollM DondiD PaezINCAPS 4 Investigators GroupJuan Lopez-MatteiPurvi ParwaniEdward NicolChiara Bucciarelli-DucciArtan GodaErvina ShirkaRoxana CampisiTomás VitaKim TaubmanJohn YoungerChristian LoeweS. MirzaeiShankar BiswasAzamal Kabir SharkerStéphane CarlierSalgado RaTim Van den WyngaertAmela BegićNejra LaticMarina Garcheva-TsachevaMetodi MihaylovStéphane SanouRob BeanlandsBenjamin ChowTeresa MassardoTamara PalavecinoJesus UrbinaXiaoli ZhangClaudia T. Gutierrez VillamilAlejandro Zuluaga SantamariaMaja Ilić TomašSlavica KovačićYamile Marcos GutierrezAmalia PeixLeonel Torres ArocheSavvas FrangosMilena HenzlovaL. GormsenBjarne NørgaardKasper KyhlMayra Sanchez VelezAdel Hassan AllamIlona MuoniDaniel Zewdneh SolomonFarzana BanoJuhani KnuutiCecile EtardF. HyafilTamar VakhtangadzeJan BuceriusDewey MarcNii Boye HammondΚωνσταντίνος ΚούσκουραςMaria KoutelouFrancisco De LeonCarla GonzalezPál Maurovich-HorvatS AravaChetan PatelErwin AffandiMajid AssadiAmjad Al-BadrJulie L. O'BrienYoav ArnsonRonen RubinshteinRoberta AssenteKakuya KitagawaTakashi KudoAkram Al‐IbraheemWaleed MahafzahTairkhan DautovKhalid MakhdomiRose Nyabanda
Key result
Diagnostic CAD testing shows marked global radiation dose variation, particularly affecting lower-income countries and CCTA.
Key Points
- To assess worldwide radiation doses during noninvasive diagnostic testing for coronary artery disease.
- Conducted a cross-sectional analysis of 19,302 adults across 742 centers in 101 countries.
- Evaluated effective doses from various imaging modalities such as SPECT, PET, CCTA, and CACS.
- Analyzed differences in doses based on geographical regions and income levels.
- Effective doses varied significantly across diagnostic modalities, with CCTA having the highest median dose at 7.4 mSv.
- Only 56% of centers performing CCTA met the recommended dose limit of 9 mSv compared to 81% for nuclear imaging.
- Radiation doses in low-income countries were up to 96% higher for CCTA compared to high-income countries.
Study Design
Type
Observational
Multicenter
Yes
Structured PICO
P
Population
Patients undergoing diagnostic imaging for coronary artery disease (CAD), particularly coronary computed tomography angiography (CCTA), worldwide.
I
Intervention
Diagnostic imaging for CAD (including CCTA)
O
Outcome
Radiation dosesafety
Discussion
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“This study shows that where a patient lives, the resources available to a health system and how those resources are used can strongly influence how much radiation they receive — even when undergoing the same test. These differences are not inevitable. In many cases, the technology and knowledge to reduce dose already exist. The challenge is ensuring that they are applied consistently and equitably across the world.”
“If you look at doses to individual patients, and if you look at Africa, the median dose for a coronary CT angiogram is five times that in Western Europe. That being the case, though, there's a lot of variation within Africa and a lot of variation within Western Europe. So, while there are trends in certain places, within every region of world there is a lot of variability.”
DPDiana PaezHead, Nuclear Medicine and Diagnostic Imaging Section, IAEA
“This research provides critical evidence that can inform national policies and international action. By identifying where radiation doses are highest and why, we can better target training, quality assurance programmes and technical support to help countries optimize cardiac imaging.”
Implication
There is a critical need for training, standardized protocols, and updated equipment to reduce the marked worldwide variation in radiation doses during CAD diagnostic imaging, particularly in low- and middle-income countries.
Abstract
IMPORTANCE: In recent decades, there has been marked worldwide growth in diagnostic testing for coronary artery disease (CAD), with several common imaging modalities exposing patients to ionizing radiation. OBJECTIVE: To examine worldwide radiation doses for patients undergoing noninvasive CAD diagnostic testing. DESIGN, SETTING, AND PARTICIPANTS: This worldwide, cross-sectional study was conducted of radiation dose from noninvasive CAD imaging in 2023, using a consecutive sample of all 19 302 adults undergoing noninvasive CAD diagnostic testing at 742 centers in 101 countries during a single week in October to December 2023. EXPOSURES: Participants underwent CAD testing with single-photon emission computed tomography (SPECT) or positron emission tomography (PET) nuclear cardiac imaging, cardiac computed tomography for coronary artery calcium scoring (CACS), or coronary computed tomography angiography (CCTA). MAIN OUTCOMES AND MEASURES: The primary outcomes were radiation effective dose to patients and the percentage of centers with median effective dose less than or equal to 9 mSv, as recommended in guidelines. RESULTS: Of 19 302 patients, 8515 (44%) were females and the median (IQR) age was 63 (54-71) years. Effective dose varied considerably across diagnostic modalities, with median (IQR) effective dose of 1.2 (0.7-2.2) mSv for CACS, 2.0 (1.6-2.4) mSv for PET, 6.5 (3.9-8.6) mSv for SPECT, and 7.4 (3.5-15.5) mSv for CCTA. Significantly more centers performing nuclear cardiology than CCTA (81% vs 56%; P < .001) and patients undergoing nuclear cardiology studies than CCTA (79% vs 56%; P < .001) achieved median dose of less than or equal to 9 mSv. Doses for the same procedure differed significantly between world regions, being lowest in Western Europe (median [IQR], 4.8 [2.3-7.3] mSv for nuclear cardiology and 4.6 [2.4-9.8] mSv for CCTA) and highest in Latin America for nuclear cardiology (median [IQR], 7.8 [5.3-9.7] mSv) and Africa (median [IQR], 25.2 [14.7-35.3] mSv) for CCTA (P < .001 for all). In regression modeling, there was an inverse relationship between country income level and dose. Patient dose was 20% (95% CI, 3.6%-38.4%) higher in low- and middle-income countries than in high-income countries for nuclear cardiology, and as much as 96% (95% CI, 41.7%-170.8%) higher in low- and lower-middle-income countries than in high-income countries for CCTA (P < .001). Marked variation was observed within income levels and world regions. CONCLUSIONS AND RELEVANCE: Given increasing rates of CAD worldwide, these findings of marked variation in radiation dose to patients from diagnostic testing identify a critical need for training, standardized protocols, and updated equipment to reduce radiation worldwide. This especially affects patients in low- and middle-income countries and patients undergoing CCTA. There are therefore important opportunities to improve the quality of CAD diagnosis for patients across the globe.
Cite This Study
Einstein et al. (2026) conducted an observational in Coronary Artery Disease (CAD). Diagnostic imaging (CCTA) was evaluated on Radiation dose variation. Diagnostic testing for coronary artery disease shows marked worldwide variation in radiation dose, particularly affecting patients in low- and middle-income countries and those undergoing CCTA.