Obesity as a determinant of radiation burden in the cardiac catheterization laboratory

Patient obesity is now a common characteristic in the cardiac catheterisation laboratory, yet its impact on radiation exposure remains under-recognised. Increased body mass index impairs X-ray penetration, prompting fluoroscopy systems to increase radiation output to maintain image quality. Consequently, patients with obesity receive substantially higher radiation doses across coronary, electrophysiological, haemodynamic, and structural heart procedures, while operators experience disproportionate increases in scatter radiation, creating cumulative occupational risk. Obesity also increases procedural complexity through more challenging vascular access, prolonged fluoroscopy, suboptimal shielding, and steeper imaging projections, further amplifying radiation burden. This review synthesises current evidence demonstrating obesity as a major procedural determinant of radiation exposure and proposes a practical obesity-aware framework incorporating fluoroscopy optimisation, shielding strategies, real-time dosimetry, enhanced radiation protection devices, workflow adaptations, and institutional quality improvement. Recognising body habitus as a core procedural variable is essential to improving radiation safety for both patients and healthcare workers while informing future obesity-specific radiation protocols.