The case for CMR

Non-invasive assessment of low- and intermediate-risk patients with chest pain

“…Although not as widely available as other modalities, stress cardiac magnetic resonance imaging (CMR) provides a robust and comprehensive assessment of myocardial perfusion imaging for the detection of CAD and accurate quantification of left ventricular morphology and function, along with myocardial tissue characterization [31,47]. CMR has the advantage of assessment of sub-endocardial perfusion abnormalities where radionuclide MPI may be falsely negative due to balanced multi-vessel CAD [22,30].…”

“…In addition, CCTA is reasonable in intermediate-risk patients who have continued symptoms after prior normal test or inconclusive exercise or pharmacological stress or are unable to undergo functional stress imaging [5]. The ACCF/AHA guidelines are comparable to the most recent revised 2013 Multi-modality Appropriate Use Criteria (AUC) for the Detection and Risk Assessment of Stable Ischemic Heart disease published in 2014 [47] (Table). In scenarios where patients are suitable for multiple modalities, clinical decisions are generally made by physician judgment based upon minimizing risks and costs to patient, local availability, and expertise.…”

Cardiac MRI for the evaluation of oncologic cardiotoxicity

“…CMR has evolved into a versatile non-invasive modality with excellent spatial and temporal resolution that offers a comprehensive assessment of myocardial function and myocardial tissue characterization, including assessment of strain, edema, diffuse fibrosis, and focal fibrosis in a single study (Figure 1). 9,10 Figure 2 illustrates the core of a contrast-enhanced CMR protocol which in most-cases can be acquired over a 30–45-minute examination. A shorter focused non-contrast protocol to assess LV function can be completed in <15 minutes.…”

Imaging the patient with a new diagnosis of heart failure in the contemporary era

“…Various etiologies of nonischemic cardiomyopathy can be suggested by the patterns of LGE, such as diffuse subendocardial enhancement in some forms of cardiac amyloid, which would allow specific diagnoses. 20 Other techniques described by the authors such as T1 mapping, and T2 weighted imaging and mapping that can interrogate features of the myocardial tissue at present are evolving, and whether results lead to specific management strategies is not as yet clear. T2* mapping in the setting of iron-overload cardiomyopathy can indeed be a valuable management tool for monitoring chelation therapy 21 and can identify myocardial iron for diagnostic purposes.…”

“…To date, there is little validation of its use in this setting, however, and it is not described by Shaw and Kramer as part of the comprehensive CMR exam of a patient with a new diagnosis of HF. 20 All of the authors have made passionate cases for their modalities of choice. Where does that leave us with this patient?…”