AJR:200, March 2013 529

all patients [57]. Therefore, by the as low as

reasonably achievable [4] principle of using
the lowest radiation possible to achieve a di-
agnosis, continued methods of radiation re-
duction should be sought to minimize patient
radiation exposure without signicantly de-
grading diagnostic imaging quality.
One potential practical strategy that phy-
sicians could employ is the use of bismuth
shields [8, 9] to reduce radiation exposure
to breast tissue among younger women dur-
ing coronary CTA (Fig. 1). Although dosim-
etry data are available with radiation reduction
at the breast tissue level ranging from 30% to
almost 60% [10], this technique has not gar-
nered widespread use and is not currently rec-
ommended by guidelines because of concerns
that unshielded techniques, such as tube cur-
rent modulation, may be superior to shield-
ing [10], concerns that breast shields could
increase radiation dose through scatter [10],
and a lack of data concerning their effect on
image quality [1113]. The impact of breast
shields on image quality of nongated thoracic
and pulmonary embolus CT studies has been
Comparison of Coronary CT
Angiography Image Quality With
and Without Breast Shields
Edward Hulten
1,2
Patrick Devine
1
Timothy Welch
1
Irwin Feuerstein
3
Allen Taylor
4
Sara Petrillo
5
Minnetta Luncheon
1
Binh Nguyen
1
Todd C. Villines
1
Hulten E, Devine P, Welch T, et al.
1
Cardiology Service, Walter Reed National Military
Medical Center, Bethesda, MD. Address correspondence
to E. Hulten (ehulten@partners.org).
2
Present address: Noninvasive Cardiovascular Imaging,
Departments of Medicine and Radiology, Brigham and
Womens Hospital, Harvard Medical School, Boston,
MA02115.
3
Food and Drug Administration, Silver Spring, MD.
4
Washington Hospital Center, Washington, DC.
5
Mid-Atlantic Kaiser Permanente Group, Rockville, MD.
Cardi opul monar y I magi ng Ori gi nal Research
AJR 2013; 200:529536
0361803X/13/2003529
American Roentgen Ray Society
C
oronary CT angiography (CTA) is
a highly accurate method for the
noninvasive evaluation of coro-
nary artery and heart disease [1].
Increased clinical utilization of coronary CTA
has resulted in concerns over potential long-
term risks of cumulative ionizing radiation re-
lated to coronary CT and other medical imaging
modalities [2]. Recent estimates of the theoretic
imposed risk from coronary CTA and other
medical ionizing radiation imaging techniques
have varied widely, and although the risk is
generally thought to be low, it may be higher
among younger women [24]. Women young-
er than 50 years who are at signicant lifetime
risk for breast cancer (the commonest malig-
nancy of women) may undergo a signicant
chest radiation dose during coronary CTA. Al-
though current dose-reduction strategies, such
as prospective ECG-triggered scanning, lower
tube potential (kilovoltage), decreased scan
length, and novel scan techniques, have been
shown to markedly reduce the estimated radia-
tion dose in coronary CTA, these techniques are
not consistently applied and are not feasible in
Keywords: breast shield, cardiac CT, coronary CT
angiography, radiation
DOI:10.2214/AJR.11.8302
Received November 23, 2011; accepted after revision
February 29, 2012.
T. C. Villines reports moderate speaker honoraria from
Boehringer-Ingelheim Pharmaceuticals unrelated to the
topic of this manuscript. All other authors have no
nancial disclosures or conicts of interest to declare.
All authors had full access to all of the data in the study
and take responsibility for the integrity of the data and
the accuracy of the manuscript.
The opinions and assertions contained herein are the
authors alone and do not represent the views of the
Walter Reed National Military Medical Center, the U.S.
Army, or the Department of Defense.
JOURNAL CLUB F
O
C
U
S

O
N
:
OBJECTIVE. The purpose of this study is to compare the image quality of coronary CT
angiography performed with and without breast shields.
MATERIALS AND METHODS. This study involved a retrospective cohort of 72 women
with possible angina who underwent 64-MDCT retrospective ECG-gated coronary CT angiog-
raphy at a single academic tertiary medical center. Images of 36 women scanned while wearing
bismuth-coated latex breast shields and 36 control subjects scanned without shields, matched
by heart rate and body mass index, were graded on a standardized Likert scale for image qual-
ity, stenosis, and plaque by two independent board-certied readers blinded to breast shields.
RESULTS. Seventy-two patients (mean [ SD] age, 53 9 years) were included. The pre scan
heart rate, body mass index, and Agatston score did not differ between groups. The median es-
timated radiation dose was 13.4 versus 16.1 mSv for those with and without breast shields (p =
0.003). For shielded versus unshielded scans, 86% versus 83% of coronary segments were rat-
ed excellent or above average (p = 0.4), median image quality was 2.0 for both groups, mean
signal was 474 75 and 452 91 HU (p = 0.27), mean noise was 33.9 8.5 and 29.8 8.3
HU (p = 0.04), and median signal-to-noise ratio was 14.4 and 14.7 (p = 0.56), respectively.
CONCLUSION. Breast shields for women undergoing coronary CT angiography slight-
ly increased noise but did not negatively affect signal, signal-to-noise ratio, quality, or inter-
pretability. Breast shield use warrants further study.
Hulten et al.
Coronary CT Angiography With and Without Breast Shields
Cardiopulmonary Imaging
Original Research
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530 AJR:200, March 2013
Hulten et al.
reported, but data for use in coronary CTA are
not available [11, 1416]. This validation re-
mains important because coronary anatomy
by CT is more technically demanding and in-
cumbent on intricately detailed image quality
when compared with nongated CT of thoracic
anatomy. Because of the potential for breast
shields to offer simple but clinically impor-
tant radiation protection, the relative lack of
breast shield use for coronary CTA vis--vis
alternative radiation protection methods, and
the lack of available image quality studies, we
undertook a comparative image quality study
of coronary CTA with and without in-plane
bismuth breast shields. Thus, the purpose of
this study is to evaluate coronary CTA im-
age quality with and without in-plane bismuth
breast shield use.
Materials and Methods
Patients
We retrospectively identied a cohort of wom-
en older than 18 years without known coronary ar-
tery disease (CAD) referred for symptoms of pos-
sible angina who underwent coronary CTA scans
with bismuth-coated in-plane latex breast shields
(AttenuRad, Cone Instruments). Such shields con-
sist of a 1-mm-thick bismuth sheet impregnated in
rubber that mounts in a foam offset. The shields
were placed on the anterior chest exterior to the
patient garments, allowed repeat use, and did not
require any special hygiene considerations beyond
that of any other medical equipment exposed to
patient contact. The cost for a medium-size breast
shield used in our study was $98.25 [17]. The
breast-shielded patients served as a convenience
sample, the use of shields having been mandated
by our institutional review boards radiation safe-
ty ofcer before approval of a research protocol
evaluating chest pain [18]. However, because the
risk-to-benet ratio of breast shields remains un-
proven, beyond the requirements of this research
protocol, bismuth shields are not otherwise re-
quired in our hospital for coronary CTA. Thus,
these patients were compared with a control pop-
ulation of 36 clinically scanned patients random-
ly selected among all women who had undergone
coronary CTA using a comparable CT acquisition
protocol without breast shields during the study
period. Patients were matched by heart rate (HR)
and body mass index (BMI), because these covar-
iates have been consistently shown to be among
the strongest patient characteristics that inu-
ence image quality on coronary CTA. All coro-
nary CTA studies were performed at Walter Reed
Army Medical Center, a single-center university-
afliated urban tertiary medical center, from Jan-
uary 2006 through February 2010. The research
protocol was approved by our hospital institu-
tional review board. Clinical information was ob-
tained from electronic health databases (inpatient,
outpatient, laboratory, and radiologic) of the De-
partment of Defense Military Healthcare System.
Coronary CTA
Per usual protocol for coronary CTA at our in-
stitution [19], all patients were prescribed variable
doses (typically 50100 mg) of oral metoprolol to
be taken 1 hour before the scheduled scan [20]. Ad-
ditional metoprolol was administered IV, if need-
ed, immediately before coronary CTA to obtain a
goal prescan HR of less than 60 beats/min. Nitro-
glycerin 0.40.8 mg sublingual was given 1 minute
before contrast-enhanced image acquisition.
All scans were performed using the same 64-
MDCT scanner (LightSpeed VCT, GE Health-
care). An initial unenhanced prospectively ECG-
triggered scan was acquired without breast shields
for calcium scoring and contrast-enhanced scan
planning. After a timing bolus series, a contrast-
enhanced scan was obtained with contrast agent
(Isovue, Bracco Diagnostics) injected IV at ow
rates of 4.56.0 mL/s through an antecubital vein,
followed by a 40-mL normal saline ush. Sixty-
four overlapping 0.625-mm slices were acquired
per rotation, with a rotation time of 350 ms. All
scans were performed using a tube potential of
120 kV. Additional acquisition variables were ad-
justed to individually optimize scans (pitch range,
0.160.25; range of tube current, 400750 mA).
When appropriate, ECG-dose modulation of tube
current was used, with maximal current output
generally occurring between 40% and 80% of the
R-R interval. Because prospectively ECG-trig-
gered scanning was not in widespread use at the
beginning of the study period, all coronary CTA
studies included in this study were retrospective-
ly ECG-gated. Scans for all patients were recon-
structed at 0.625-mm slice thickness using ltered
back projection and the GE Healthcare standard
soft-tissue kernel.
Existing scans were previously interpreted
jointly by a cardiologist and a radiologist trained
in the performance and interpretation of coronary
CTA. For the assessment of image quality for our
study, noncardiac ndings were not reassessed.
For the assessment of coronary ndings for our
retrospective study, the scans were independent-
ly reread by two independent cardiac CT board-
certied readers using the Society of Cardiovas-
cular CT 18-segment coronary model [21] while
blinded to use of breast shields, clinical variables,
symptoms, and the original scan clinical interpre-
tation. To achieve blinding, one researcher loaded
Fig. 1Appearance of bismuth in-plane breast shields.
A, Shield is shown in position on patients chest.
B, Shield is shown with 10-cm ruler.
C and D, Breast shield can be seen at top of axial slice from
64-MDCT cardiac CT angiography image (C) and in 3D
reconstruction of same image (D).
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AJR:200, March 2013 531
Coronary CT Angiography With and Without Breast Shields
all image series and panned the breast shield and
anterior chest tissue from the FOV on the work-
station before coronary evaluation by the two
blinded readers. After independent interpretation,
each segment was then read and scored by consen-
sus. Complete datasets from 36 women scanned
with bismuth-coated latex breast shields and 36
HR- and BMI-matched female control subjects
scanned without breast shields were randomly
graded on a standardized Likert scale for quality,
stenosis, and plaque presence and type (i.e., non-
calcied, partially calcied, or entirely calcied)
[21, 22]. Specically, segments were graded us-
ing all available acquired phases for image qual-
ity and for the worst stenosis within each segment,
in accordance with Society of Cardiovascular CT
guidelines [21]. Quality ranged from 1 (excellent),
2 (good), 3 (below average), to 4 (uninterpretable).
Stenosis severity was graded as 0 (no stenosis), 1
(< 25% diameter worst stenosis), 2 (2549% ste-
nosis), 3 (5069% stenosis), 4 ( 70% stenosis),
and 5 (100% stenosis). Plaque within each seg-
ment was rated as noncalcied (no appreciable
calcium within the plaque or segment), partially
calcied, or entirely calcied by each rater. Seg-
ments smaller than 1.5 mm were not assessed, and
anatomically absent segments (e.g., ramus) were
coded as missing. Coronary calcium was quanti-
ed according to the Agatston method [23]. Im-
age signal and image noise were measured as the
mean ( SD) of Hounseld units within a 1-cm di-
ameter region of interest in the aortic root and at
the level of the left main coronary artery origin,
respectively [21]. Signal-to-noise ratio was calcu-
lated as the signal divided by the noise. Estimated
radiation dose in millisieverts was calculated as
the dose-length product multiplied by the conver-
sion factor for chest CT of 0.014 [6].
Statistical Analysis
Continuous variables with normal distributions
were expressed as mean ( SD) and were com-
pared using Student t test for independent groups
and one-way analysis of variance for between
group comparisons. Categorical variables were
expressed as frequencies (percentages) and were
compared by the Pearson chi-square test. Vari-
ables with skewed distributions were expressed as
median (interquartile range [IQR]) and were com-
pared by Mann-Whitney U test. Interrater reliabil-
ity was measured with the kappa statistic. Because
of a skewed distribution, calcium scores were nat-
ural logtransformed before analysis for trends;
one was added to zero calcium scores. A two-
tailed p value less than or equal to 0.05 was con-
sidered signicant. All analyses were performed
using Stata (version 11.0, StataCorp).
Results
Seventy-two patients with a mean age of
53 9 years were included. The prescan HR
was 56 10 beats/min, BMI was 30 5 kg/m
2
,
median Agatston score was 0 (IQR, 014; 32%
of scores were > 0), and the estimated radiation
dose was 14 5 mSv (Tables 1 and 2).
Of 1296 theoretically possible coronary
segments for 72 patients using an 18-segment
coronary model, 17% were anatomically ab-
sent and 14% were rated as too small (< 1.5
mm). Arteries that were depicted on the the-
oretic 18-segment model but were absent or
too small were most commonly ramus, left
posterolateral, left posterior descending, and
second obtuse marginal segments. Among
891 segments rated, 99% of graded coronary
segments were evaluable (10 segments were
noninterpretable because of poor image qual-
ity secondary to coronary motion). The me-
dian quality rating for both shielded and un-
shielded patients was good (2 [IQR, 220]).
There was no signicant difference between
groups in the prevalence of normal, nonob-
structive (< 50% worst stenosis), and ob-
structive ( 50%) CAD (Table 3). There were
slightly higher rates of no coronary plaque
(9% prevalence difference; p < 0.001) and
slightly lower rates of noncalcied plaque
(2% difference; p =0.012) and partially cal-
cied plaque (6% difference; p < 0.001) in
the shield group, although rates of calcied
and noncalcied plaque were similar (Table 3).
Evaluation of segments located closer to the
shield did not identify an effect of proximity to
breast shield placement on image quality score
TABLE 1: Demographics of Patients Who Underwent Coronary CT
Angiography With and Without Breast Shields
Characteristic
Without Shield
(n = 36)
With Shield
(n = 36) p
Age (y), mean SD 54.1 1.7 51.3 1.5 0.27
a
Body mass index, mean SD 29.9 0.9 29.2 0.8 0.84
a
Hypertension, no. (%) of patients 22 (61) 19 (53) 0.48
a
Hyperlipidemia, no. (%) of patients 21 (58) 15 (42) 0.16
a
Smoking, no. (%) of patients 2 (6) 4 (11) 0.39
a
Family history, no. (%) of patients 15 (42) 5 (14) 0.01
a
Diabetes mellitus, no. (%) of patients 4 (11) 2 (6) 0.39
a
Heart rate (beats/min), median (IQR) 54 (4762) 55 (5061) 0.66
b
Left ventricular ejection fraction (%), median (IQR) 72 (6277) 66 (5873) 0.29
b
NoteIQR = interquartile range.
a
Student t test or chi-square test.
b
Wilcoxon rank-sum test.
TABLE 2: Results of Coronary CT Angiography With and Without
Breast Shields
Result Without Shield (n = 36) With Shield (n = 36) p
Agatston score
Median (IQR) 0 (029) 0 (02) 0.44
a
Minimum 0 0 Not applicable
Maximum 563 784 Not applicable
Tube current (mA), median (IQR) 593 (573642) 606 (575643) 0.47
a
Dose-length product, median (IQR) 1151 (8891405) 956 (8301060) 0.003
a
Radiation dose (mSv), median (IQR) 16.1 (12.420.0) 13.4 (11.614.8) 0.003
a
Signal (HU), mean SD 452 91 474 75 0.27
b
Noise (HU), mean SD 29.8 8.3 33.9 8.5 0.04
b
Signal-to-noise ratio, median (IQR) 14.7 (11.521.7) 14.4 (11.717.9) 0.56
a
Image quality score, median (IQR) 2 (22) 2 (22) 0.50
a
NoteIQR = interquartile range.
a
Wilcoxon rank-sum test.
b
Student t test or chi-square.
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532 AJR:200, March 2013
Hulten et al.
(for shielded vs unshielded patients, distal left
anterior descending quality, 2 vs 2 [p = 0.4];
mid-left anterior descending quality, 2 vs 2
[p = 0.8]; and proximal right coronary artery,
2 vs 2 [p = 0.4]).
Table 4 shows predictors of image quality
by univariate and multivariate linear regres-
sion. BMI ( = 0.018; p < 0.0001) was signif-
icant after multivariate analysis. As depicted
in Figure 2, comparing scans with and with-
out breast shields, 86% versus 83% of coro-
nary segments were rated as excellent or good
(p = 0.4). There was no statistically signicant
difference in the percentage of below-average
(poor) quality or nonevaluable segments for
shielded patients (14%) compared to unshield-
ed patients (17%; p = 0.39). Patients without
shields had a small, but signicantly higher,
number of uninterpretable segments (n = 9)
compared with shielded patients (n = 1; p =
0.01). There was a small but statistically sig-
nicant increase in image noise of 4 HU (14%
relative increase) between scans performed
with (33.9 1.4 HU) and without (29.8 1.4
HU) breast shields (p = 0.04). There was no
statistically signicant difference in mean sig-
nal (474 75 vs 452 91 HU; p = 0.27) and
median signal-to-noise ratio (14.4 vs 14.7; p =
0.56) for scans performed with and without
shields. At the segment level, none of the 18
coronary segments was signicantly differ-
ent between shielded and unshielded patients
for quality, stenosis severity, or plaque score.
Interrater agreement was excellent for quality
( = 0.82; p < 0.001), stenosis ( = 0.82; p <
0.001), and plaque ( = 0.83; p < 0.001).
Discussion
Coronary CTA is a sensitive test [1, 24]
to exclude obstructive CAD in symptomatic
patients, but at the risk of signicant radia-
tion exposure [6, 2527]. In-plane bismuth-
coated latex breast shields are one of sever-
al radiation dosereduction techniques that
have been evaluated for chest CT, although
their use in coronary CTA has been limited
by concerns regarding their potential adverse
impact on image quality [8, 9].
Our study retrospectively compared image
quality among young women without known
CAD who underwent coronary CTA with and
without breast shields. Although the study was
retrospective and observational in design, we
controlled or evaluated for important con-
founding variables. Specically, patients were
matched for HR and BMI, IV contrast agent
volume and type was the same between groups,
and all patients received -blockade to mini-
mize cardiac motion artifacts. In addition, all
scans were done with a tube potential of 120
kV on the same 64-MDCT coronary CTA
scanner with similar acquisition parameters
and radiation doses. Where confounders could
not be controlled, we evaluated for signicant
differences. Importantly, there was no differ-
ence in HR, BMI, tube current, Agatston
score, or CAD prevalence and severity be-
tween the two groups.
We evaluated image quality in several ways
that could potentially relate to breast shield use
during coronary CTA. There was no difference
in any of the 18 segments rated using a stan-
dardized scale for quality, stenosis, and plaque
assessment. A strength of these assessments
was the excellent interrater reliability ( = 0.82;
p < 0.001). Of note, there was a small but statis-
tically signicant increase in noise (33.9 vs 29.8
HU with and without breast shields, respective-
ly; p = 0.04); however, there was no difference
in mean Hounseld unit signal or signal-to-
noise ratio. Importantly, 99% of all rated seg-
ments were interpretable, and there was no
difference between groups in the percentage
of segments rated good or average or the
percentage rated below average. This nd-
ing suggests that the coronary CTA technique
used in this cohort was likely performed at a
higher radiation dose than necessary. Studies
TABLE 3: Coronary Artery Stenosis Severity and Plaque Composition,
as Evaluated on a Per-Segment Basis, After Coronary CT
Angiography With and Without Breast Shields
Variable Without Shield With Shield p
Worst stenosis (n = 36)
None 19 (53) 25 (69) 0.15
< 50% stenosis 17 (47) 10 (28) 0.09
50% stenosis 0 (0) 1 (3) Not applicable
Plaque type (n = 884)
No plaque 350 (79) 390 (88) < 0.001
Noncalcied 31 (7) 20 (5) 0.012
Partially calcied 55 (12) 26 (6) < 0.001
Calcied 6 (1) 6 (1) 1.0
NoteData are no. (%) of plaques. p values were calculated by Student t test or chi-square test.
TABLE 4: Results of Univariate and Multivariate Regression Analysis for
Predictors of Image Quality
Type of Analysis, Predictor p
Univariable
Heart rate 0.008 0.002
Age 0.002 0.44
Body mass index 0.021 < 0.001
Agatston score 0.02 0.096
Radiation dose 0.15 0.078
Left ventricular ejection fraction 0.004 0.18
No disease vs disease 0.06 0.24
Breast shields 0.016 0.76
Multivariable
Heart rate 0.005 0.051
Body mass index 0.018 < 0.001
Radiation dose 0.034 0.66
Agatston score 0.013 0.25
NoteHeart rate was measured as beats/min, age was measured in years, body mass index was measured
as kilograms per meter squared, radiation dose was measured as millisieverts, and left ventricular ejection
fraction was measured as a percentage.
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AJR:200, March 2013 533
Coronary CT Angiography With and Without Breast Shields
investigating the impact of breast shields using
more current radiation dosereduction tech-
niques, such as lower tube potential and pro-
spective ECG-triggered scans, are warranted
and were not assessed in this study. There was
a higher rate of noninterpretable segments,
paradoxically, in the unshielded group (9 vs
1), although the numbers were small and may
represent a type I error.
The effect of breast shields on dose reduc-
tion specic to breast tissue was not directly
quantied in our study but has been report-
ed by previous authors in pediatric chest CT
[14], adult thoracic noncoronary CT [11, 15,
16], and coronary calcium scans [9]. In such
dosimetry studies measuring radiation pre-
cisely at the breast tissue, dose reduction to
the breast achieved by breast shields has been
reported to be as much as a statistically signif-
icant 37.1% [9]. Although no published prior
study, to our knowledge, has evaluated breast
shield use in vivo for coronary CTA, more re-
cently, because of ongoing interest in ways to
avoid radiation during coronary CTA, the ef-
fect of breast shields on coronary CTA image
quality and radiation dose has been evaluated
in a phantom model [28]. In that study, simi-
lar to our ndings, breast shield use was as-
sociated with a small but signicant increase
in image noise of 2.3 HU (6.8%; p = 0.005).
The impact of this change in image noise and
tissue attenuation should be evaluated in ad-
ditional in vivo studies similar to ours; the
effect of such changes on the clinical inter-
pretation of scans is not known and is of spe-
cial concern, because interest has grown in
describing coronary plaque risk according to
plaque shape and attenuation characteristics.
One hesitation for the use of breast shields
is that CT providers may increase the overall
dose delivered or avoid dose-reduction tech-
niques during the scan to overcome the per-
ceived decrement in image quality imparted by
breast shields, thereby increasing radiation to
nonbreast tissues, such as lung tissues, which
have an even greater lifetime risk of malig-
nancy. The present study suggests that breast
shields may be used effectively without a clin-
ically signicant adverse effect on image qual-
ity or a secondary increase in estimated effec-
tive radiation dose. Specically, the presence
of breast shields did not appear to result in pro-
viders increasing dose technique because of
the presence of breast shields or in a perceived
negative impact on image quality. Further study
on the impact of breast shields on image qual-
ity among patients undergoing scans at lower
tube potential, among patients who are at higher
risk for obstructive CAD, and using prospective
ECG-triggering is warranted.
The study is limited by its retrospective ob-
servational design. To minimize confounding,
we controlled via HR and BMI matching and
used the same scan protocol (i.e., tube poten-
tial, HR control, same scanner, and ECG-gat-
ing technique). In spite of efforts to control all
known confounders, we cannot exclude the
possibility that the similarity in noise between
groups is due to an uncontrolled confounder
because of the observational study design. For
example, although breast tissue volume corre-
lates with BMI, we did not control specically
for breast tissue volume, and this could attenu-
ate radiation and inuence noise. On the other
hand, a recent study of breast phantoms eval-
uating image quality for coronary CTA with
and without breast shields did not nd an ef-
fect of breast size on image quality [28]. The
sample size could be considered somewhat
small but is relatively robust for an image
quality study, especially at the per-segment
level (891 segments graded excellent, good,
below average, or uninterpretable and scored
for plaque and stenosis). Given that breast
shields are not mandated for use at most insti-
tutions, whereas they were required for some
research protocols by our hospitals institu-
tional review board, our cohort of 36 women
scanned with breast shields is one of the larg-
est and is a convenient real-world sample of
this radiation dose reduction technique.
In addition to these study design limita-
tions, we also would like to summarize the
additional concerns with regard to breast
shield use, as applicable to coronary CTA.
These important concerns and limitations in
the available data have been highlighted in
the diverging opinions of several recent edi-
torials [10, 29, 30]. A major concern of those
opposed to breast shield use stems from the
following principle [30]:
...using bismuth (or any other attenuat-
ing element) shielding within the scan
range violates a fundamental rule of ra-
diation protection by wasting radiation.
The shield attenuates photons coming
from the anterior direction, reducing ra-
diation dose to the supercial (anterior)
organs. However, when the tube irradi-
ates the patient from the posterior direc-
tion, the shield also attenuates the pho-
tons exiting the patient. Because these
photons have already passed through and
delivered dose to the patient, stopping
them as they leave the patient produces
no dose reduction. However, removing
photons exiting the patient does remove
a substantial amount of useful signal for
creating the CT images. This leads to
a noise increase across the entire image,
not just in the region near the shield.
First, as already discussed, the fact that
images remain interpretable even with high-
er noise suggests that the total radiation dose
could be reduced before considering interven-
tions such as breast shields. Currently, the use
of retrospective ECG-triggered scans and 120-
kV tube potential is much less common at our
institution, and the impact of shields in current
dose-reduced scans warrants study. Similarly,
our study found increased noise with shields
but was not limited by streak or other artifacts
100
80
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(
%
)
Image Quality
60
40
20
Excellent Good Below
Average
No shield
Shield
Uninterpretable
0
Fig. 2Graph shows
no difference in image
quality with and without
breast shields. There
was small number of
uninterretable segments
in both groups (1 among
shielded patients
vs 9 for unshielded
patients) that did reach
signicance, but in
opposite direction
of what would be
hypothesized if shields
adversely affected
image quality, and is
likely type I error.
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534 AJR:200, March 2013
Hulten et al.
qualitatively. It is unknown whether such arti-
facts, which have been reported in some stud-
ies of breast shields, would limit coronary
CTA when conducted at lower tube potential
and with further radiation-reduction strate-
gies. Second, breast shields may trap and scat-
ter radiation and paradoxically increase dose
at the breast-tissue level, although the change
in dose resulting from scatter due to shields is
currently debated [31].
Third, as already noted, concern has been
raised that breast shield use may indirectly in-
crease radiation dose to the lung tissue, and
lung cancer has an even higher lifetime risk
than breast cancer; however, there was a re-
duction of radiation to both breast and lung
tissue in a recent phantom study of breast
shield use during coronary CTA [28]. Fourth,
the shielded patients had a higher percent-
age of normal coronary segments and fewer
segments with partially calcied or noncal-
cied plaque (Table 3) versus the unshielded
patients. This nding may accurately reect
small between-group differences in plaque
distribution and composition but warrants ad-
ditional study, because breast shield use re-
sulting in radiation attenuation and associated
increased noise may decrease the sensitivity
for plaque detection and the accurate assess-
ment of plaque composition, although this hy-
pothesis is speculative at this time.
Finally, continued advances in other radia-
tion-reduction techniques may minimize the
relative benet of radiation savings of breast
shielding, whereas their use in a lower radiation
setting could potentially adversely affect im-
age quality. The impact of breast shields would
need to be restudied in concert with each of
these subsequent radiation-reduction technol-
ogies, especially, for example, automated tube
current modulation, the performance of which
may be adversely affected by radiation attenu-
ation such as that resulting from breast shields.
In spite of these limitations, to our knowl-
edge, this study is the only cohort that has eval-
uated coronary CTA image quality in vivo
during real-world use with and without breast
shields. Breast shield use is not ready for wide-
spread clinical practice because of concerns
about image noise and tissue attenuation and
its effect on other radiation-reduction technolo-
gies (e.g., automated tube current modulation),
but it nevertheless should be further evaluated
as one part of a multifaceted dose-reduction
strategy to minimize future risk of malignancy
associated with coronary CTA.
In conclusion, the use of breast shields in
women undergoing coronary CTA slightly
increased noise but did not adversely affect
signal, signal-to-noise ratio, coronary arte-
rial segment image quality, or overall rates
of study interpretability. Our study serves
only as an assessment of image quality in
the presence or absence of breast shields and
is not sufcient evidence to recommend the
routine use of breast shields. However, as a
potential radiation-reduction technique, the
use of breast shields in women undergoing
coronary CTA warrants further study.
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30. McCollough CH, Wang J, Berland LL. Bismuth
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F O R Y O U R I N F O R M AT I O N
This article has been selected for AJR Journal Club activity. The accompanying Journal Club
study guide can be found on the following page.
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536 AJR:200, March 2013
Hulten et al.
Study Guide
Comparison of Coronary CT Angiography Image Quality With and
Without Breast Shields
Alan Mautz, Joseph J. Budovec, Margaret Mulligan*
Medical College of Wisconsin, Milwaukee, WI
amautz@mcw.edu, jbudovec@mcw.edu, mmulliga@mcw.edu
Introduction
1. What is the research question being asked? What are the null and alternative hypotheses?
2. What are the current clinical indications for coronary CT angiography? Do these indications vary between sexes?
3. What dose-reduction strategies may be used for coronary CT angiography?
Methods
4. What is the design of this study? What are the limitations of this study? How were patients selected?
5. How was image quality evaluated? What measurements were used to assess image quality?
6. What confounding factors were controlled for in this study? Are there additional variables the study should have controlled for?
7. How did the study ensure blinding of the interpreting radiologists to the presence or absence of the breast shield? Was this blinding
adequate?
Results
8. What question does this study answer? What other questions does the study raise?
9. What factors inuence coronary CT angiography image quality?
Physics
10. Briey review how radiation dose from CT examinations is calculated and discuss how scanning parameters can be altered to modulate
dose.
Discussion
11. Recent editorials have called into question the use of bismuth breast shields (see McCollough et al., J Am Coll Radiol 2011; 8: 878879) as
violating a fundamental principle of radiation protection. Does the study adequately address this concern?
12. Does your institution use bismuth breast shields? If so, under what circumstances? When might use of these shields be disadvantageous?
Background Reading
1. Hausleiter J, Meyer T, Hermann F, et al. Estimated radiation dose associated with cardiac CT angiography. JAMA 2009; 301:500507
2. Fricke BL, Donnelly LF, Frush DP, et al. In-plane bismuth breast shields for pediatric CT: effects on radiation dose and image quality using experimental and
clinical data. AJR 2003; 180:407411
3. McCollough CH, Wang J, Berland LL. Bismuth shields for CT dose reduction: do they help or hurt? J Am Coll Radiol 2011; 8:878879
APPENDIX 1: AJR JOURNAL CLUB
*Please note that the authors of the Study Guide are distinct from those of the companion article.
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