A Nurse’s Role in

Developing an
Advanced Cardiac Imaging
Program
j Anna G. MacDonald, RN

ABSTRACT: With the rapid advancement of present day imaging equipment, advanced cardiac imaging has
moved to the forefront of noninvasive modalities. The ease of use, the diagnostic accuracy of the 64-slice
gated computed tomography (CT) scanner and the new pulse sequences for MRI scanners has made a multitude
of diagnostic possibilities available.
In London, Ontario, Canada after the installation of new CT and MR scanners, four departments, Cardiology,
Nuclear Medicine, Radiology, and Imaging Research pooled financial resources to create a Cardiac Imaging
Nurse Coordinator position dedicated to develop, facilitate, and coordinate an advanced cardiac imaging pro-
gram. This program development was unique as the imaging modalities were in one facility and the In- and
Outpatient Cardiac Program (cardiology and cardiovascular surgery) were in another. (J Radiol Nurs
2008;27:123-129.)

Cardiac computed tomography (CT) and cardiac mag-
netic resonance imaging (MRI) are two new imaging
modalities in the field of advanced cardiac imaging.
In the last several years, cardiac imaging has advanced
significantly with the introduction of the 64-slice CT
scanner and the MRIs with faster pulse sequences. A
multitude of diagnostic possibilities have become avail-
able, because of their ease of use and diagnostic accu-
racy. Patients with low to intermediate probability of
heart disease can now have noninvasive procedures to
establish the presence or absence of coronary disease.
The extent of the disease, the structure of the heart,
and function of the heart muscle can be visualized
clearly and accurately.
The city of London, Ontario, with a population of
380,000 has two large health care institutions. Four
Anna G. MacDonald, RN, is at St. Joseph’s Health Care/London
Health Sciences Centre, London, Ontario, Canada.
Corresponding author: Anna G. MacDonald, RN, St. Joseph’s Health
Care/London Health Sciences Centre, 268 Grosvenor Street, Room
E5104, London, Ontario, N6A 4V2, Canada. E-mail: annag.
macdonald@lhsc.on.ca
1546-0843/$34.00
Copyright Ó 2008 by the American Radiological Nurses Association.
doi: 10.1016/j.jradnu.2008.06.002
inter-related departments within these health care facil-
ities felt it was necessary to share these new imaging
techniques with one another in a coordinated fashion.
To this end, cardiology, radiology, imaging research,
and nuclear medicine pooled financial resources to cre-
ate a cardiac imaging nurse coordinator’s (CINC’s)
position. This position was dedicated to develop, facil-
itate, and coordinate an advanced cardiac imaging pro-
gram, for both clinical and research applications. This
was a full time 2-year contract position (40 hr a week)
dividing time with all respective departments (see Table
1). CINC devoted time and resources to work closely
with the CT/MRI staff and booking departments to en-
able adequate time allotments and full use of scanning
availability.
An interesting situation existed in the city of
London: all of the cardiac imaging services were in an
outpatient facility; in-patients, outpatients, and cardiac
surgical services were in another hospital. The chal-
lenge that existed was to introduce these noninvasive
cardiac imaging services to the cardiologists, cardiac
surgeons, and internists, who would have historically
ordered an invasive procedure to further delineate a
patient’s diagnosis. How were these imaging modalities
going to be introduced to cardiologists, surgeons, and
other physicians? How could we influence doctors to

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MacDonald JOURNAL OF RADIOLOGY NURSING Advanced Cardiac Imaging Program

Table 1. The role of the CINC

1. CINC acts as a resource person for advanced cardiac imaging both clinically and for research.
2. CINC screens patients by ensuring criteria are met for imaging to take place for both CT and MRI.
a. That is, blood creatinine level, patient is experiencing symptoms with inclusive other noninvasive testing such as mibi, stress test or atypical
chest pain.
b. Stable outpatient
c. Sinus rhythm or a controlled atrial fibrillation rate of 70 beats per minute.
d. No active reversible airway obstructions (contraindications to metoprolol administration).
3. CINC assures reports of other cardiac imaging modalities are available (ie, ECG, catheterization, coronary stent insertion, nuclear medicine,
surgical reports).
4. CINC facilitates CT and MRI procedures by booking procedures with referring physicians, patient instruction given.

CINC, cardiac imaging nurse coordinator; CT, computed tomography; MRI, magnetic resonance imaging.

‘‘buy’’ into these new imaging techniques given the
potential impact on their financial compensation?
Scan time was reserved on a weekly basis for cardiac
CT imaging and biweekly for Cardiac MRI imaging in
the facility that had both the 64-slice CT scanner and
the MRI scanner with cardiac software. A cardiac radi-
ologist was available to interpret films, and technical
and nursing staffs were in place to scan and care for
these types of patients, respectively.
A vital component of this undertaking was the edu-
cation of the CINC by the cardiac radiologist on the
function and capabilities of the CT and MRI scanners.
Understanding the fundamentals of the scanners and
how they worked was deemed necessary to ‘‘sell’’ these
new diagnostic-imaging modalities to the physicians.
CINC clinical background was important to the intro-
duction of these imaging techniques. The CINC came
with working experience in a cardiac care unit, cardiac
catheterization laboratory and interventional radiol-
ogy. These areas all played an integral role in the un-
derstanding of cardiac anatomy and components of
radiology nursing. An educational CD was developed
with the guidance of the cardiac radiologist and the
program cardiologist. This CD presented cardiac im-
ages from the CT and MRI scanners, along with the
clinical and diagnostic indications for their use (see
Table 2 and 3). The CD was able to show first hand
what information on imaging and the type of informa-
tion they would receive postscanning. Over a 6-month
period, the CINC held formal educational sessions
with most of the cardiologists within the city, either in-
dividually or in groups to introduce these imaging mo-
dalities, their respective capabilities, and the indications
for cardiac, CT, and MR.
Another important component of the program, to
maximize its success, was the modification of the Pic-
ture Archiving and Communication Systems ordering
system. To ease the transition to a citywide program
there was need to differentiate between CT thorax
and CT heart. This system was modified to accept
cardiac imaging orders.
With cardiac CT, heart rate control is a key factor in
obtaining diagnostic quality images and reducing radi-
ation to the patient. CT scanners with dose modulation
(electrocardiograph [ECG] monitoring during the CT
scan) are ideal for cardiac CT scans, where the radia-
tion dose is adjusted according to the cardiac phase.
As the heart is in constant motion, images are acquired
during diastole when the heart is at rest. The CT scan-
ner is adjusted to deliver most of the CT tube’s output
during diastole, and decreases the amount of radiation
during systole. This should be performed in retrospec-
tively gated studies to limit radiation exposure.
Prospective ECG gating is also available, where ra-
diation is administered only in predefined snapshots
during the cardiac cycle, rather than during the whole
cycle as it is with retrospective gating. With a regular
ReR interval, image quality is vastly improved, partic-
ularly for CT scans of coronary arteries. Prospectively
gated studies have a significantly lower dose of

Table 2. Indications for cardiac coronary CT

(1) Unusual symptoms for coronary artery disease (such as chest pain unrelated to physical exertion), low to intermediate risk profiles for cor-
onary artery disease
(2) Unclear or inconclusive stress test (treadmill) results
(3) Inclusive myocardial perfusion scans
(4) Assess patency of bypass grafts.
(5) Also useful in evaluating: myocardium, coronary artery distribution, pulmonary veins, thoracic aorta, adults with congenital heart disease
(surgical repairs)

CT, computed tomography. Data from Hendal, et al 2006.

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Advanced Cardiac Imaging Program JOURNAL OF RADIOLOGY NURSING MacDonald

Table 3. Indications for cardiac MRI Presently the use of IV metoprolol has decreased, as
(1) Myocardial viability, extent of scar/fibrosis
the use of an oral b-blocker has proved to be successful
(2) Right ventricular abnormalities in bringing the heart rate within reasonable rates for
(3) Cardiomyopathy/myocarditis/sarcoid/hypertrophic obstructive coronary CT angiography (CTA). Cardiac-specific pa-
cardiomyopathy tient information sheets were developed for CT and
(4) Pericardial disease MRI. The following patient information sheets are cur-
(5) Cardiac tumors
(6) Valvular disease
rently being used in the CT and MR facility and given to
(7) Congenital heart disease before and after surgical repair patients at the time of booking. Discharge instructions
(8) Thoracic aortic disease are given to patient after the cardiac CT (see Table 5).
(9) Great vessel arteritis

Data from Hendal, et al 2006.

radiation compared with retrospectively gated studies

with dose modulation. If a patient should present
with a heart rate more than 65 beats/min, it would be
necessary to pharmacologically suppress the heart
rate using a parentally administered b-blocker. Meto-
prolol tartrate (BetalocÒ) is the b-blocker of choice,
as the cost and short duration of effect (half-life) is ad-
vantageous for use in the CT Suite for cardiac imaging
acquisitions. Diltiazem hydrochloride may be used if
the patient has hypersensitivity or contraindications
to a b-blocker, or significant reversible airway obstruc-
tion that may be aggravated by b-blocker administra-
tion. Presently metoprolol tartrate is given in two
forms, either intravenous (IV; betaloc) or PO (by
mouth; apo-metoprolol). Referring physicians may
give patients a prescription for oral metoprolol tartrate
to be taken before coming to the imaging center, CARDIAC COMPUTED TOMOGRAPHY
whereas others are given a b-blocker on arrival to the ANGIOGRAM
patient preparation area. Patients are required to fast
from solids 4 hr before the scan but are encouraged Patient information sheet
to drink at least 1 L of water before coming to the im- A traditional CT scan is an x-ray procedure that com-
aging center. Patients answer questions regarding pres- bines many x-ray images with the aid of a computer to
ent medications, previous contrast injections, contract generate pictures of the body. Cardiac CT uses ad-
reactions, smoking, and any health problems, such as vanced CT technology with IV contrast (dye) to visual-
diabetes and/or asthma, and whether they have taken ize your cardiac anatomy, coronary circulation, and
erectile dysfunction medications (eg, viagra, cialis) great vessels.
within the last 24e48 hr. Medications such as nitrates
Your doctor uses the cardiac CT to evaluate
are important to be aware of as the patients are given
 the heart muscle
a spray of nitroglycerine before acquiring images for
 the coronary arteries
optimal coronary vasodilation. The registered nurses,
 the pulmonary veins
who worked with the program, would administer IV
 the thoracic and abdominal aorta
metoprolol/diltiazem, if needed, which in some institu-
 the sac around the heart (pericardium)
tions would require a physician to administer. With this
in mind, medical protocols were formally developed for
the administration of b-blockers or calcium channel
blockers intravenously, by a registered nurse with
proper training (see Table 4). This was done over sev- How to prepare
eral meetings with pharmacists, pharmacy committees,  Please fast from solid foods 4 hours prior to the
and the Medical Emergency Response Team (MERT) time of your scan. Drink at least 2-3 cups of water
of the facility where the cardiac imaging was to take if morning appointment and 3 to 4 cups of water if
place (see Table 4). Protocols were put in place for ad- afternoon.
verse reactions to the administration of the b-blocker.  Take all medications as ordered

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MacDonald JOURNAL OF RADIOLOGY NURSING
 If you are on a b-blocker, please take morning of
examination
 Avoid any caffeinated drinks on the day of your
examination. Coffee, tea, energy drinks, or caf-
feinated sodas.
 Do not use Viagra or any similar medication on
the day before or the day of the examination. It
is not compatible with the medications you will
receive during the procedure (ask your doctor if
you have questions).
 If you are diabetic, ask your physician how to ad-
just your medications the day of your test. If you
think your blood sugar is low, tell the technolo-
gist immediately.
 Tell your technologist and your doctor if you are
B Pregnant
B Allergic to iodine and/or shellfish or any
medications
B Undergoing radiation therapy
B Older than 60 years or have a history of
kidney problems (you may be required to
have a blood test to evaluate your kidney
function before receiving any contrast
agent).
What to expect
 You will change into a hospital gown.
 An IV line will be started in a large vein in your
arm to administer contrast (dye) during your
procedure.
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Advanced Cardiac Imaging Program
 Your BP, heart rate will be taken to determine if
a drug is needed to lower your heart rate for the
examination.
 You will lie on a special scanning table.
 The technologist will clean three small areas of
your chest and place small, sticky electrode
patches on these areas. Men may expect to have
their chest partially shaved to help the electrodes
stick. The electrodes are attached to an ECG
monitor, which charts your heart’s electrical ac-
tivity during the test.
 You will be asked to hold your breath for 15
seconds. While taking the pictures, we will ask
you not to move or breathe during that time.
Try practicing your breath holds if you think
this may be a problem. For example, taking
2e3 deep breaths and then holding your breath
for about 15 seconds.
 You will lie on the scanner table, and you will be
asked to place your arms behind your head for
the duration of the examination, for about
15 minutes.
 During the scan, you will feel the table move in-
side a donut-shaped scanner. You will receive
a contrast agent through your IV to help produce
the images. It is common to feel a warm sensation
as the contrast circulates through your body.
 Once the technologist is sure that all the informa-
tion is collected, the IV will be removed.
The CT scan takes about 15 minutes.
After the procedure
 You may continue all normal activities and eat as
usual after the test.
 If given a medication to slow your heart down
(metoprololÒ or Diltiazem), you will be asked
to stay for approximately 1-hr postprocedure to
monitor your heart rate and blood pressure.
For a short period of time, you may feel dizzy,
drowsy, or notice a headache after medication
administration.
We ask that you arrange for a driver to take you
home if medications are given to lower your heart rate.
Please list all the medications you are taking presently
and bring them with you the day of the examination.
MRI HEART PATIENT INFORMATION
MRI is a test that produces high quality still and mov-
ing pictures of the heart and great vessels. MRI uses
large magnets (a large magnet) and radio-frequency
waves to produce pictures of the body’s internal struc-
tures; no x-ray exposure is involved. MRI acquires in-
formation about the heart as it is beating, creating
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Advanced Cardiac Imaging Program JOURNAL OF RADIOLOGY NURSING MacDonald

Table 4. Medical protocol for metoprolol administration

Who can implement this protocoldrole criteria/qualifications
Radiology interventional nurse/cardiac imaging nurse
Educational Requirement for registered nurse to administer b-blocker
Qualifications
1. Basic cardiac life support
2. Advanced cardiac life support (preferred)
3. Able to insert IV lines
4. Completion of self-learning package ‘‘IV Direct Medication Administration’’
5. RN trained in and able to analyze ECG monitoring, in more than one lead
6. Ability to monitor patient’s heart rate, blood pressure, ECG, O2 saturation
7. Experience in cardiac catheterization laboratory and administration of parenteral metoprolol in that setting and observation of patients’
response to those drugs
, Meets with above qualifications, except where nurse has no experience in a catheterization laboratory and will be mentored by a qual-
ified nurse until such time the ordering physician, the qualified nurse, and the nurse performing the protocol are comfortable with care
and outcomes of patients receiving b-blocker
, The Registered Nurse new to monitoring patients receiving metoprolol IV will have given and cared for a minimum of 10 patients
receiving metoprolol IV
What is being ordered: IV direct administration of a metoprolol

Criteria for decision in protocol: clinical conditions required to implement above orders
A medication order for a b-blocker will be written by the attending Radiologist responsible for the coronary CTA who will be in attendance in the
CT suite, and readily available if needed.
Patient selection: patients older than 18 years.
All patients with a heart rate of O65 beats/min and systolic blood pressure O100 mm Hg are eligible to receive at least one dose of 2.5 mg
metoprolol IV to reduce heart rate.
Heart rate goal for metoprolol therapy is determined based on resting heart rate as follows:
(1) If resting heart rate is !100 beats/min, then goal heart rate is 60e70 beats/min.
(2) If resting heart rate is O100 beats/min, then goal heart rate is 75e85 beats/min.
Patient is to have a cardiac CT coronary angiogram or specific need to determine intracardiac anatomy.
Patients needing metoprolol to lower their heart rate will be actively monitored by noninvasive BP, ECG, O2 saturation ECG: patient in NSR or
controlled atrial fibrillation (noncoronary cardiac indications)

Under what circumstances would this order be contraindicated

 Clinical evidence of heart failure: elevated JVP, chest rales on auscultation. History of any recent treatment for heart failure
 Clinical evidence of bronchospasm at the time of the study
 Asthma requiring regular use of bronchodilators

Documentation
 Outpatient surgery documentation record will be used, for all medications given, IV start, and recording of all vital signs taken.

Guideline for procedure

 A large bore (18-gauge or larger preferred) angiocatheter will be placed in the antecubital, with saline lock before CT. An IV infusion may or
may not be started.
 Baseline blood pressure, HR, and O2 oximetry will be obtained with patient lying on a stretcher.
 If metoprolol is needed for increased heart rate, inject 2.5 mg IV slowly over 1 min.
 Monitor BP and HR every 2e3 min before each dose.
 If target HR is not obtained, one may repeat dose of metoprolol 2.5 mg slowly over 1 min to a maximum of 15 mg of metoprolol, with intervals
of 5 min between doses.
 Atropine should be readily available, along with resuscitation equipment.
 IV fluid should be readily available.
 Contrast consent form
 Radiology requisition requesting examination and any documentation faxed from the referring Physician’s office notes will be part of the chart
and sent to medical records.
 Doctor’s order sheet for medications given during procedure, ie, b-blocker, SL nitro
 Patient will be monitored for 1 hr postmetoprolol injection

IV, intravenous; ECG, electrocardiograph; CT, computed tomography; CTA, computed tomography angiography; BP, blood pressure; HR,
heart rate.

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MacDonald JOURNAL OF RADIOLOGY NURSING
Table 5. Discharge instructions for patients postcardiac
CTA
1. Please do not drive for 4 hr if you have been given an IV b-
blocker
2. You may continue normal activities
3. Take all medications as ordered and may continue with normal
diet
4. Please call the radiology department if you develop a rash within
the next 48 hr.
5. Drink at least 1,500 cc of fluid throughout the rest of the day to
aid in excretion of the contrast media used.
CTA, computed tomography angiography.
moving images of the heart throughout its pumping
cycle.
YOUR DOCTOR USES THE MRI TO EVALUATE
(1) The anatomy and function of the structures of
the chest: heart, great vessels, and pericardium
(2) The location and extent of heart muscle injury
HOW TO PREPARE
 If you are not claustrophobic (fear of closed
spaces)
B You will not require any sedation.
B Eat as usual.
B Take your medications as usual.
 If you are claustrophobic
B You may ask your doctor to schedule your
MRI with sedation (a medication to help
you relax).
If you take a sedative, you may not eat any solid food
for 6 hr before receiving your sedative to avoid nausea.
You may have clear liquids (apple juice, jello, black
coffee or tea, water) up to 2 hr before your medication
time.
You may take your regular medications unless your
doctor advises against it.
For your safety, bring a companion to drive you
home. Take your regular medication with sips of
water.
If you do not require sedation, do not request it.
Bring your favorite CD.
The MRI uses powerful magnets to create its images.
For your safety, anyone undergoing a scan should be
free of certain metallic or magnetic items. Inform the
MRI staff if you have any metallic implants or any
metal under the skin. Most metallic implants, such as
sternal wires and mediastinal clips used for heart sur-
gery, pose no problem.
128 www.radiologynursing.org
Advanced Cardiac Imaging Program
Tell your doctor if you have any of the following
conditions.
 Implanted pacemaker or defibrillator
 Cerebral aneurysm clip (metal clip in a blood ves-
sel in the brain)
 Pregnancy
 Implanted insulin pump, narcotic pump, or im-
planted nerve stimulators (TENS) for back pain
 Metal in the eye or eye socket
 Cochlear (ear) implant for hearing impairment
 Stentsdwhile most stents are safe, some stents
may not be
 Wear a shirt or blouse that can be easily removed.
Women should wear a bra that can be easily re-
moved before the examination. You may wear
metal-free pants, such as sweatpants with elastic
bands, during the test. A gown will be provided.
Leave the following items at home, if possible:
B Belt buckles
B Metal zippers
B Snaps
B Watches
B Wallets with bank or credit cards with mag-
netic strips
WHAT TO EXPECT
 An MRI technologist will prepare you for your
scan.
 You will change into a hospital gown.
 The technologist will place small sticky, electrode
patches on your chest and back. Men may expect
to have their chest partially shaved to help the
electrodes stick. The electrodes are attached to
an ECG monitor, which charts your heart’s elec-
trical activity during the test.
 Most likely, an IV line will be inserted into a vein
in your arm for contrast (dye) administration.
The MRI scanner unit is a long tube that scans the
body as you lie on a platform bed. It is fully lit and ven-
tilated, and open at both ends. Keeping your eyes
closed during the examination will help avoid claustro-
phobia. The MRI technologist will be talking to you
throughout the examination and you will not be left
alone. You will lie on your back on the scanner bed.
 Your head and legs will be elevated, using a sup-
porting pillow for comfort. During the examina-
tion, you will be asked to lie as still as possible.
The technologist will ask you to hold your breath
periodically for short periods (15 s) to reduce blur-
ring of the images caused by breathing motion.
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Advanced Cardiac Imaging Program JOURNAL OF RADIOLOGY NURSING
 During scanning, you may hear loud banging
noises, which can be muffled with headphones
or earplugs, which you will receive before scan-
ning begins.
 Bringing your favorite CD may be helpful
The MRI scan takes about 30e75 min, depending
on the extent of the imaging needed.
AFTER THE PROCEDURE
 If you received sedation
B The MRI technician will give you instruc-
tions on when you can eat, drink, and
return to normal activities. A companion
should drive you home.
 If you did not receive sedation, you may resume
your usual activities and normal diet immediately.
With the introduction of this coordinated program and
the position of CINC, the future of cardiac imaging in
London looks progressive and positive. The program
started with scanning 3e4 patients a week and pres-
ently there are about 12e16 cardiac CT cases done
weekly. During the first year of this program there
has been well over 650 scans completed. Along with
the increase in cardiac CT, there has been a steady in-
crease in cardiac MR referrals. Already patients have
benefited from the program and have benefited our
health care system.
Benefits to Ontario patients have included a decrease
in wait times for coronary angioplasty and stenting,
a decrease in normal result coronary angiograms, its
use as a guide for prognosis and target setting for ther-
VOLUME 27 ISSUE 4 www.radiologynursing.org
MacDonald
apy (CT and MRI), its use in image guidance for surgi-
cal and percutaneous procedures. Image guidance will
decrease risk and improve success rates, that is, viabil-
ity, distal runoffs of coronary arteries. Also, calcium
scoring may be used for future risk management.
In conclusion, this program would not have been
successful without the collaboration of radiologists
and cardiologists, appropriate equipment, trained per-
sonnel to perform procedures, referrals by physicians
that did ‘‘buy in,’’ and radiology administration that
supported the program. The CINC plays a critical
role in triage of referrals and directing patients to the
appropriate test to answer the clinical question.
Acknowledgments
I would like to acknowledge Dr. Ali Islam, our Cardiac Radiol-
ogist who read this manuscript, along with Dr. Gerald Wisen-
berg who were vital to make this program a success.
Reference
Hendal, R.C., Patel, M.R., Kramer, C.M., & Poon, M. (2006).
ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006
appropriateness criteria for cardiac computed tomography
and cardiac magnetic resonance imaging: A report of
the American College of Cardiology Foundation/
American College of Radiology, Society of Cardiovascular
Computed Tomography, Society for Cardiovascular
Magnetic Resonance, American Society of Nuclear Cardiol-
ogy, North American Society for Cardiac Imaging, Society
for Cardiovascular Angiography and Interventions, and
Society of Intterventional Radiology. J Am Coll Cardiol,
48, 1475-1497.
129