Education in Heart

NON-INVASIVE IMAGING

Cardiovascular magnetic resonance evaluation of the patient with known or suspected coronary artery disease
Michael Schmid, Werner G Daniel, Stephan Achenbach
Department of Internal Medicine 2, University Hospital of Erlangen, Erlangen, Germany Correspondence to Dr Michael Schmid, Department of Internal Medicine 2, University Hospital of Erlangen, Ulmenweg 18, 91054 Erlangen, Germany; michael. schmid@uk-erlangen.de

Cardiovascular magnetic resonance (CMR) imaging is nding an increasing role in the diagnosis of cardiac disease. In many instances, CMR provides valuable information and for some aspects, such as left ventricular function, is considered to be the diagnostic gold standard.1 Among the most important advances is the implementation of balanced steady state free precession (SSFP) sequences that provide higher signal-to-noise ratio than can be obtained by conventional gradient echo techniques, along with excellent delineation of the bloodemyocardium interface. The SSFP technique has become the preferred cardiac CMR pulse sequence for acquisition of volumetric datasets of the left and right ventricle. Parallel acquisition techniques allow image acquisition times to be substantially shortened. Next to imaging of cardiac morphology CMR has several distinct applications that are of use in assessing patients with chest pain. First of all, CMR is currently considered the gold standard for quantication of ventricular volumes, biventricular global and regional function, and mass.1 Even small motion abnormalities can be reliably detected due to free choice of tomographic plane, high spatial resolution, as well as excellent delineation of endo- and epicardial borders (gure 1). Compared to echocardiography, CMR provides more precise data and is associated with lower interobserver and interstudy variability. For stress testing, this can be of particular advantage and improved accuracy of stress CMR over echocardiography has been demonstrated in patients with poor echocardiographic windows2 (gure 2). Of major interest is the ability of CMR to visualise myocardial scar directly by using a segmented inversion recovery gradient echo sequence at least 10 min after the intravenous injection of gadolinium contrast (gure 1). This method, termed delayed gadolinium enhancementCMR (DGE-CMR), unmasks non-viable, irreversibly damaged myocardium as a hyperenhanced or bright area in a manner that closely correlates to histopathology ndings.3 Compared to nuclear imaging, CMR provides substantially higher spatial resolution, allowing better delineation of small

areas of infarct, and also small areas of viable myocardium.4 It is important to note that DGE is not strictly associated with ischaemic myocardial necrosis. Since ischaemic myocardial disease starts at the subendocardium and spreads like a wavefront in the transmural direction, other distinct distribution patterns of scar and brosis (eg, inammatory, inltrative) can be differentiated.5 Myocardial brosis, in a non-coronary distribution pattern, can be detected in up to 30% of patients with nonischaemic dilated cardiomyopathy, and frequently appears as mid wall septal hyperenhancement (mid wall striae) (gure 3). Moreover, CMR allows imaging of myocardial perfusion. Protocols to assess rst pass perfusion at rest as well as during dobutamine, dipyridamole or adenosine induced stress have been developed and validation studies demonstrated high accuracy for identication of patients with coronary artery disease (CAD).6 Finally, T2 weighted CMR imaging offers the ability to detect myocardial oedema in vivo on the basis of increased water content due to post-ischaemic or inammatory myocardial tissue injury. A combined approach of T2 weighted and DE-CMR allows visualisation of reversible as well as irreversible myocardial injury and differentiation of acute from chronic irreversible injury (gure 4)7. CMR is often considered to provide comprehensive information in patients with known or suspected CAD. Imaging can be completed routinely within a time frame of 45e60 min and provides information regarding global and regional left ventricular function, scar and viability, as well as myocardial perfusion (including microvascular obstruction), and, in the case of acute coronary syndrome (ACS), myocardial oedema (gure 5). While functional assessment of valvular heart disease is possible due to the ability of CMR to quantify blood ow accurately, imaging of the coronary arteries themselves is currently not a clinical application. In this article we discuss various CMR imaging modalities that may be considered in several typical clinical scenarios involving patients with known or suspected CAD.
Heart 2010;96:1586e1592. doi:10.1136/hrt.2008.152637

1586

Education in Heart

Figure 1 End-diastolic (A) and end-systolic (B) frames from a vertical long axis view of the left ventricle (two chamber view) with circumscribed apical and infero-apical hypokinesia (arrows). Corresponding delayed enhancement image (C) demonstrates a subendocardial infarction of the apicoanterior, apical and infero-apical walls (arrows).

THE STABLE PATIENT WITH A HISTORY OF CHEST PAIN

In order to identify the presence of coronary artery stenoses in patients with stable chest pain, CMR offers two basic approaches: wall motion analyses by dobutamine stress magnetic resonance, and imaging of myocardial perfusion by vasodilatation (adenosine) stress CMR. Both are considered appropriate for investigating patients with intermediate pre-test likelihood of CAD who are unable to exercise or who have an un-interpretable ECG, and the relevance of coronary artery stenoses remains unclear after invasive coronary angiography.1

Wall motion imaging during high dose dobutamine stress

Dobutamine stress CMR is performed using the same incremental dobutamineeatropine protocol as applied in stress echocardiography. CMR has the inherent advantage of higher spatial resolution, higher reproducibility, and true long and short axis imaging with contiguous parallel slices.2 Nandalur et al published a meta-analysis of 735 patients and found an overall sensitivity of 83% and specicity of 86% to detect signicant CAD as dened by a stenosis of $50% at catheterisation.6 Clinically, the detection of new or worsening wall motion abnormalities in patients who have pre-existing wall motion abnormalities at rest is especially challenging. In 160 patients with pre-existing wall motion abnormalities who underwent dobutamine stress CMR, Wahl et al demonstrated a sensitivity of 89% and a specicity of 84% for the detection of signicant CAD.8 The sensitivity of detecting single, double, and triple vessel disease was 87%, 91%, and 100%, respectively. It has also been demonstrated that dobutamine stress CMR offers prognostic information. In a prospective study of 299 patients, Kuijpers et al demonstrated a positive and negative predictive value of 95% and 93%, respectively, for development of major adverse cardiac events. The 2 year cardiac event-free survival rate in patients with suspected myocardial ischaemia but a negative dobutamine stress CMR was 96.2%.9

Magnetic resonance perfusion imaging

Magnetic resonance imaging (MRI) offers the assessment of rst pass myocardial perfusion with high spatial resolution of 2e3 mm, which even permits differentiation of transmural and sub-endocardial perfusion defects. Many recent publications have shown that CMR myocardial perfusion imaging has similar or superior diagnostic accuracy to the more established nuclear techniques for myocardial perfusion imaging.10 11 Ishida et al evaluated 104 patients with stress myocardial perfusion CMR, selective coronary angiography, and stress myocardial perfusion single photon emission computed tomography (SPECT). They
1587

Figure 2 Dobutamine stress magnetic resonance wall motion short axis images at rest (A, B) and at maximum stress (C, D) showing end-diastolic (left) and end-systolic (right) frames. Cardiac magnetic resonance imaging displays normal wall motion at rest. At peak dose dobutamine a pronounced anteroseptal hypokinesis (arrows) could be observed. Coronary angiography revealed a high grade stenosis of the proximal left anterior descending artery.
Heart 2010;96:1586e1592. doi:10.1136/hrt.2008.152637

Education in Heart
detection of CAD.12 Klem et al studied 100 consecutive patients referred for invasive coronary angiography and found that sensitivity, specicity, and accuracy of CMR myocardial perfusion alone were 84%, 58%, and 68%, respectively, but were improved to 89%, 87%, and 88%, respectively, by including the information obtained from delayed enhancement imaging.12 Table 1 summarises the published stress perfusion CMR studies with coronary angiography comparison. Furthermore, a negative CMR myocardial perfusion study seems to be associated with an excellent long term prognosis. Several studies have emphasised the high negative predictive value of CMR myocardial perfusion imaging for event-free survival.13e15 In a prospective study by Jahnke et al, the 3 year event-free survival for patients with normal CMR myocardial perfusion imaging and dobutamine stress CMR was 99.2%.14 In a group of 218 patients with suspected CAD, Pilz et al showed that a normal adenosine stress CMR with absence of DGE predicts a 99% survival free of major adverse cardiac events over 12 months.15 Figure 3 Examples of different patterns of delayed gadolinium enhancement cardiac magnetic resonance imaging. Subepicardial and intramural delayed gadolinium enhancement (arrows) in inferolateral wall in long axis (A) and corresponding short axis view (B) is typical for myocarditis. Mid wall brosis (C), most pronounced in the septum (arrows), can be seen in up to 28% of patients with dilated cardiomyopathy. Hyperenhancement from the thickened parietal and visceral pericardium (arrowed), with a small rim of pericardial effusion (asterisk) between, is characteristic of acute pericarditis (D). reported sensitivities of 85%, 96%, and 100% for CMR to detect single, double, and triple vessel disease as dened by conventional coronary x-ray angiography ($70% diameter stenosis), respectively. The overall specicity of perfusion CMR for identication of patients with signicant coronary artery stenoses was 85% at a per-patient level. Perfusion CMR was superior for detection of CAD in comparison with SPECT.10 Recently published studies which combine CMR myocardial perfusion and delayed enhancement imaging have demonstrated signicant improvements in the overall diagnostic performance of this technique for the

THE PATIENT WITH ACUTE CHEST PAIN AT REST

CMR is currently not considered a routine imaging tool in patients with acute chest pain.1 However, several recent research studies have highlighted the potential of CMR to contribute to the assessment of these patients, and especially to differentiate ACS from other forms of chest pain. CMR imaging provides characteristic patterns of delayed gadolinium enhancement and wall motion abnormalities that allow a differentiation between patients with acute chest pain from coronary and non-coronary origin.16 However, using delayed enhancement and wall motion alone, it may be difcult to differentiate acute ischaemia from chronic myocardial infarctiondboth will typically exhibit wall motion abnormalities and late enhancement. While chronic infarction is more likely to be associated with a thin wall, this nding is not specic for nonviable myocardium. In this context, T2 weighted CMR has been introduced recently and may contribute considerably to the identication of

Figure 4 Short axis and parasternal long axis views from a patient with acute anteroseptal myocardial infarction. The oedema gives a bright signal on T2 weighted (fat suppressed) image (A). Delayed gadolinium enhancement image shows a bright area with a central black core corresponding with microvascular obstruction (B). The transmural extent of the infarction is well visualised in the short axis view (C).
1588 Heart 2010;96:1586e1592. doi:10.1136/hrt.2008.152637

Education in Heart
Kwong et al demonstrated in a prospective feasibility study of 161 consecutive patients with chest pain not associated with ST elevation that CMR can be successfully used for triage of these patients in the emergency department.16 They assessed perfusion, left ventricular function and delayed enhancement within 12 h of presentation. The sensitivity and specicity, respectively, for detecting subsequent ACS ($70% coronary stenosis or positive stress test) were 84% and 85%. CMR had 100% sensitivity for non-ST segment elevation myocardial infarction. Furthermore, the study has shown that CMR is more accurate than standard clinical tests including the Thrombolysis in Myocardial Infarction (TIMI) score (p0.004), troponin I (p<0.001), and ECG criteria for ischaemia (p<0.001) to predict the diagnosis of ACS or critical coronary stenosis. Plein et al were the rst to demonstrate, in a higher risk group of patients with documented non-ST segment elevation ACS, that the combined use of several CMR methods (wall motion, perfusion, delayed enhancement viability imaging) can accurately predict signicant coronary stenosis on x-ray angiography ($70%), with a sensitivity of 97% and a specicity of 83%.18 In another study, Ingkanisorn et al recently reported that a normal adenosine CMR examination in patients presenting to the emergency department with acute chest pain was associated with the absence of a diagnosis of CAD during follow-up and the absence of adverse cardiovascular outcomes.13 In this study of 135 troponin negative patients, adenosine perfusion abnormalities had 100% sensitivity and 93% specicity for detection of signicant CAD, and were the single most accurate component of the CMR examination. Adenosine can be safely administered to patients with suspected or established ACS in the magnetic resonance environment.12 18 In the setting of acute chest pain, diagnosing acute myocarditis may be challenging. In this scenario, CMR is a helpful modality that enables assessment of the presence and extent of inammatory myocardial damage, concomitant pericardial involvement, and the impact on regional and global left ventricular function. CMR can delineate the oedema caused by inammation, and DGE imaging allows visualisation of even small myocardial injuries that cannot be identied by any other non-invasive imaging method. Importantly, the pattern of DGE allows differentiation from ischaemic injury, since DGE in myocarditis does not follow coronary territories and typically is not located subendocardially, as in ischaemic necrosis16 (gure 3). A combined approach with T2 weighted imaging and contrast enhanced T1 weighted imaging allows differentiation between reversible and irreversible myocardial damage, and helps to assess the acuity of inammation. Pericarditis is another potential diagnosis in patients with acute chest pain. CMR can provide a detailed and comprehensive examination of the pericardium and heart. Using a combination of T1, T2, cine sequences, and delayed enhancement, MR
1589

Figure 5 Comprehensive cardiac magnetic resonance imaging study with cine function, adenosine perfusion, and delayed enhancement of a patient with subacute myocardial infarction of the inferior wall. The rst two images refer to the diastolic (A) and systolic (B) frame of the cine series in the short axis plane of the left ventricle. The arrows indicate akinesis of the inferior wall segment. The dense, partially transmural perfusion defect during stress (C) extends in spatial extent the scarred area on delayed enhancement image (D), indicating that there is peri-infarct ischaemia. The delayed enhancement pattern typically involves the subendocardium and extends towards the subepicardium. ACS, since it can be used to detect a reversible myocardial injury.7 Black-blood T2 weighted sequences delineate areas of myocardial oedema due to active inammation based on a water-excitation pulse. Cury et al used a combination of T2 weighted imaging, rst pass perfusion, left ventricular function, and delayed enhancement imaging in 62 emergency room patients with acute chest pain and reported that the specicity (96%), positive predictive value (85%), and overall accuracy (93%) for identifying patients with ACS was signicantly improved over a standard protocol without T2 weighted images (84%, 55%, and 84%, respectively).17

Table 1 Sensitivity, specicity and accuracy of stress perfusion cardiovascular magnetic resonance imaging for detecting coronary artery disease with angiography comparison
Author Cheng Merkle Klem Cury Plein Paetsch Wolf Nagel Ishida Year 2007 2007 2006 2006 2004 2004 2004 2003 2003 Number of patients 61 228 92 46 68 79 99 84 104 Sensitivity (%) 98 93 89 97 96 91 93 88 90 Specicity (%) 76 86 87 75 83 62 75 90 85 Accuracy (%) 90 91 88 88 94 81 85 89 88 Stenosis denition (%) $50 >70 $70 $70 $70 >50 $70 $75 $70 Prevalence of CAD (%) 66 81 40 65 82 67 62 51 74

CAD, coronary artery disease.

Heart 2010;96:1586e1592. doi:10.1136/hrt.2008.152637

Education in Heart
can identify pericardial inammation and differentiate pericardial effusion from thickened pericardium. It must be taken into account that atrial brillation or other arrhythmias may often be present in pericardial disease. MR images will often still be diagnostic in such patients, but image quality is often reduced substantially. CMR imaging in patients with acute chest pain may also enable detection of other underlying disease such as stress cardiomyopathy (tako tsubo), non-ischaemic cardiomyopathies,5 thoracic aortic aneurysm, aortic dissection and intramural aortic haematoma or pulmonary embolism. In summary, CMR therefore constitutes a technique that can provide valuable information on cardiac disease and important differential diagnoses in acute chest pain patients. Cost and examination time, ad hoc availability of a scanner, and the requirement for sufcient operator expertise may be an obstacle to implementing CMR as a routine diagnostic tool for emergency room patients with acute chest pain. 2000, Kim et al studied patients who had left ventricular dysfunction and underwent bypass surgery, and found contractile improvement in 78% of patients with no scar versus only 2% of patients with myocardial scars that extended over >75% of the myocardial thickness.19 Currently, a transmural extent of 50% is considered the threshold beyond which contractile recovery is unlikely.

Prognosis
Due to its high spatial resolution, delayed gadolinium enhancement imaging can even visualise discrete areas of subendocardial infarctions and appears thereby more sensitive than SPECT and positron emission tomography.20 The extent and pattern of enhancement have incremental prognostic and therapeutic implications beyond the established clinical, angiographic, and functional predictors. In a trial of 1366 consecutive patients with known or suspected CAD referred for CMR, the presence of myocardial scar detected by DGE was the most powerful predictor of cardiac events, followed by left ventricular ejection fraction.21 A report by Kwong et al showed that the presence of even small areas of myocardial scar identied by DGE imaging in a group of 187 diabetic patients, of whom 109 had no known prior myocardial infarction, predicted a more than fourfold increased incidence of major adverse coronary events compared to those with no DGE.22 Furthermore, DGE-CMR imaging has the ability to visualise new areas of necrosis in a subset of patients after percutaneous coronary intervention due to distal embolisation of plaque contents. The resulting new local myocardial injury is associated with a signicantly reduced myocardial perfusion reserve.23 The severity of myocardial infarction seems to be best assessed with DGE-CMR detected microvascular obstruction, termed no-reow phenomenon. Despite restoration of epicardial blood ow, damaged microvasculature restricts contrast access and leads to a non-enhancing central dark core inside a bright area of DGE (gure 4). A recent study by Nijveldt et al established that the presence of microvascular obstruction in 60 patients with acute myocardial infarction treated with primary stenting was the most powerful predictor of recovery of regional and global function, more powerful than transmural extent of infarction, TIMI ow grade, myocardial blush grade, and ST segment resolution.24 Only 6% of 372 dysfunctional segments with microvascular obstruction showed complete recovery during follow-up compared with 35% of the 1786 dysfunctional segments without microvascular obstruction (p<0.0001).

THE PATIENT WITH CHRONIC CONGESTIVE HEART FAILURE DUE TO CAD (ISCHAEMIC CARDIOMYOPATHY)
Underlying CAD and subsequent ischaemia as well as myocardial infarction are responsible for approximately two thirds of all cases of systolic dysfunction, and distinction from non-ischaemic aetiology of heart failure has important therapeutic and prognostic implications. CMR has the ability to identify the presence and to quantify the exact transmural extent of myocardial scarring or brosis in patients with ischaemic cardiomyopathy, independent of wall motion or reperfusion status. Additionally, contrast enhanced CMR can accurately delineate between irreversible myocardial ischaemic injury and dysfunctional but viable myocardium (hibernating or stunned myocardium).

Viability assessment
Compared to normal myocardium, infarcted myocardium appears hyperenhanced in T1 weighted pulse sequences after intravenous injection of gadolinium. Such CMR sequences for detection of delayed enhancement are well established, thoroughly validated and increasingly used to assess myocardial viability precisely with high spatial resolution and excellent tissue contrast.19 Clinically, delayed enhancement MRI has developed into the reference standard for myocardial viability imaging.1 A CMR scan for the assessment of viability can be performed in less than 30 min.

Prediction of functional response to revascularisation therapy

The location, extent and transmurality of delayed enhancement make it possible to predict viability and functional recovery after revascularisation. The likelihood of contractile recovery decreases with increasing transmural extent of delayed hyperenhancement. In their landmark study published in
1590

Left ventricular dysynchrony

The combination of viability testing and assessment of dysynchrony by CMR has recently been shown to differentiate between responders and non-responders to resynchronisation therapy in patients with ischaemic heart failure in New York Heart Association (NYHA) functional class IIIeIV.25
Heart 2010;96:1586e1592. doi:10.1136/hrt.2008.152637

Education in Heart
pacing, usually do not respond to cardiac resynchronisation therapy.25 Furthermore, recently published studies provide evidence that the myocardial scar morphology in patients with ischaemic left ventricular dysfunction as assessed by delayed enhancement CMR has the potential to predict the likelihood of malignant ventricular arrhythmias and sudden cardiac death risk.26

Cardiac magnetic resonance imaging in the patient with chest pain: key points
In stable patients with a history of chest pain, cardiac magnetic resonance (CMR) imaging can: < provide comprehensive information regarding left ventricular function, myocardial viability, ischaemia and valvular heart disease. < identify the presence of coronary artery stenoses with two different basic approachesdwall motion analysis by dobutamine stress CMR or vasodilatation (adenosine) stress CMR. In patients with acute chest pain at rest, CMR can: < differentiate acute coronary syndromes from other forms of chest pain, thereby enabling early interventional therapy. < delineate areas of myocardial oedema with T2 measurement due to postischaemic or inammatory myocardial tissue injury. < visualise reversible as well as irreversible myocardial injury and differentiate acute from chronic injury with a combined approach of T2 weighted and delayed enhancement imaging. In patients with chronic congestive heart failure, CMR can: < be considered the non-invasive gold standard for assessment of viability using SSFP cine and delayed enhancement imaging. < differentiate ischaemic from non-ischaemic myocardial disease due to the distribution pattern of scar and brosis. < delineate between irreversible myocardial ischaemic injury (scar) and dysfunctional but viable myocardium. < predict the likelihood of contractile recovery after revascularisation.
The assessment of dysynchrony can be performed using tagged cine imaging. With the use of saturation prepulses, grid oriented landmarks can be placed over the imaging plane. Based on their deformation due to ventricular contraction, regional strain and peak contraction can be calculated. Bleeker et al demonstrated that patients with left ventricular dysynchrony and transmural scar in the posterolateral wall, the target region for left ventricular

LIMITATIONS OF CMR
In patients with implanted ferromagnetic materials, such as pacemakers, debrillators, some cerebral aneurysm clips and retained shrapnel, MRI is contraindicated. Currently, the imaging industry is trying to develop CMR compatible devices. About 4% of patients are too claustrophobic to tolerate a CMR examination. Traditional CMR methods may fail in patients with severe ventricular dysfunction and orthopnoea, who have difculty complying with prolonged breathhold commands and lying supine for extended periods of time. New magnetic resonance systems with open design and real-time acquisition without the need for breath holding may effectively address this problem in the near future. Of concern are some recent reports that the use of gadolinium containing contrast agents, particularly the non-ionic linear chelates (Omniscan and OptiMARK), in patients with severe renal insufciency is associated with a new scleroderma-like disorder, termed nephrogenic systemic brosis. There is no robust evidence to suggest that haemodialysis performed within 24 h after the gadolinium application can prevent nephrogenic systemic brosis. Therefore, contrast enhanced CMR imaging should be used very cautiously in patients with severe renal impairment (glomerular ltration rate <30 ml/min) until more denitive data are available.
Competing interests In compliance with EBAC/EACCME guidelines, all authors participating in Education in Heart have disclosed potential conicts of interest that might cause a bias in the article. Stephan Achenbach has received research grants from Siemens and Bayer Schering Pharma. He has received consulting fees from Servier. Provenance and peer review Commissioned; not externally peer reviewed.

You can get CPD/CME credits for Education in Heart

Education in Heart articles are accredited by both the UK Royal College of Physicians (London) and the European Board for Accreditation in Cardiologydyou need to answer the accompanying multiple choice questions (MCQs). To access the questions, click on BMJ Learning: Take this module on BMJ Learning from the content box at the top right and bottom left of the online article. For more information please go to: http://heart.bmj.com/misc/education. dtl < RCP credits: Log your activity in your CPD diary online (http://www. rcplondon.ac.uk/members/CPDdiary/index.asp)dpass mark is 80%. < EBAC credits: Print out and retain the BMJ Learning certicate once you have completed the MCQsdpass mark is 60%. EBAC/ EACCME Credits can now be converted to AMA PRA Category 1 CME Credits and are recognised by all National Accreditation Authorities in Europe (http://www.ebac-cme. org/newsite/?hitmen02). Please note: The MCQs are hosted on BMJ Learningdthe best available learning website for medical professionals from the BMJ Group. If prompted, subscribers must sign into Heart with their journals username and password. All users must also complete a one-time registration on BMJ Learning and subsequently log in (with a BMJ Learning username and password) on everyvisit.

REFERENCES
1. Hendel RC, Patel MR, Kramer CM, et al. 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 Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. J Am Coll Cardiol 2006;48:1475e97. Nagel E, Lehmkuhl HB, Bocksch W, et al. Noninvasive diagnosis of ischemia-induced wall motion abnormalities with the use of high-dose dobutamine stress MRI: comparison with dobutamine stress echocardiography. Circulation 1999;99:763e70. Simonetti OP, Kim RJ, Fieno DS, et al. An improved MR imaging technique for the visualization of myocardial infarction. Radiology 2001;218:215e23. One of the major breakthroughs in the eld of CMR imaging was the development of gadolinium delayed enhancement techniques to identify and quantify myocardial infarction.

2.

3.
<

Heart 2010;96:1586e1592. doi:10.1136/hrt.2008.152637

1591

Education in Heart
4. Ibrahim T, Bulow HP, Hackl T, et al. Diagnostic value of contrastenhanced magnetic resonance imaging and single-photon emission computed tomography for detection of myocardial necrosis early after acute myocardial infarction. J Am Coll Cardiol 2007;49:208e16. Mahrholdt H, Wagner A, Judd RM, et al. Delayed enhancement cardiovascular magnetic resonance assessment of non-ischaemic cardiomyopathies. Eur Heart J 2005;26:1461e74. Comprehensive review on the use of delayed contrast enhanced CMR in differentiating ischaemic from nonischaemic cardiomyopathy and description of the underlying histopathological background of the different types of hyperenhancement. Nandalur KR, Dwamena BA, Choudhri AF, et al. Diagnostic performance of stress cardiac magnetic resonance imaging in the detection of coronary artery disease: a meta-analysis. J Am Coll Cardiol 2007;50:1343e53. The largest meta-analysis to date showing that stress CMR imaging is highly accurate in detecting CAD. Friedrich MG, Abdel-Aty H, Taylor A, et al. The salvaged area at risk in reperfused acute myocardial infarction as visualized by cardiovascular magnetic resonance. J Am Coll Cardiol 2008;51:1581e7. This paper describes the ability of T2 weighted imaging to detect myocardial oedema and to visualise the salvaged area at risk in patients with reperfused acute myocardial infarction. Wahl A, Paetsch I, Roethemeyer S, et al. High-dose dobutamineatropine stress cardiovascular MR imaging after coronary revascularization in patients with wall motion abnormalities at rest. Radiology 2004;233:210e16. Kuijpers D, van Dijkman PR, Janssen CH, et al. Dobutamine stress MRI. Part II. Risk stratication with dobutamine cardiovascular magnetic resonance in patients suspected of myocardial ischemia. Eur Radiol 2004;14:2046e52. Ishida N, Sakuma H, Motoyasu M, et al. Noninfarcted myocardium: correlation between dynamic rst-pass contrastenhanced myocardial MR imaging and quantitative coronary angiography. Radiology 2003;229:209e16. Schwitter J, Wacker CM, van Rossum AC, et al. MR-IMPACT: comparison of perfusion-cardiac magnetic resonance with singlephoton emission computed tomography for the detection of coronary artery disease in a multicentre, multivendor, randomized trial. Eur Heart J 2008;29:480e9. The MR-IMPACT study in 234 patients reported improved detection of coronary stenosis by CMR compared with SPECT in the rst multicentre, multivendor comparison. Klem I, Heitner JF, Shah DJ, Sketch MH Jr, et al. Improved detection of coronary artery disease by stress perfusion cardiovascular magnetic resonance with the use of delayed enhancement infarction imaging. J Am Coll Cardiol 2006;47:1630e8. Ingkanisorn WP, Kwong RY, Bohme NS, et al. Prognosis of negative adenosine stress magnetic resonance in patients presenting to an emergency department with chest pain. J Am Coll Cardiol 2006;47:1427e32. First emergency room study illustrating the excellent prognostic value of adenosine stress CMR in patients with acute chest pain and myocardial infarction excluded by serial troponin assays. Jahnke C, Nagel E, Gebker R, et al. Prognostic value of cardiac magnetic resonance stress tests: adenosine stress perfusion and dobutamine stress wall motion imaging. Circulation 2007;115:1769e76. Pilz G, Jeske A, Klos M, Ali E, et al. Prognostic value of normal adenosine-stress cardiac magnetic resonance imaging. Am J Cardiol 2008;101:1408e12. 16.
<

5.
<

17.

<

6.

<

18.

7.

19.
<

<

8.

20.

9.

21.

10.

22.

11.

<

<

23.

12.

24.

<

13.

<

25. 26.

14.

<

15.

Kwong RY, Schussheim AE, Rekhraj S, et al. Detecting acute coronary syndrome in the emergency department with cardiac magnetic resonance imaging. Circulation 2003;107:531e7. The rst prospective emergency room study which showed that CMR imaging is more sensitive than troponin I measures and TIMI trial risk score for detecting acute ACS in patients presenting with chest pain and a non-diagnostic ECG. Cury RC, Shash K, Nagurney JT, et al. Cardiac magnetic resonance with T2-weighted imaging improves detection of patients with acute coronary syndrome in the emergency department. Circulation 2008;118:837e44. The rst study demonstrating that the incorporation of T2 weighted imaging into a standard protocol with rst pass perfusion, late gadolinium enhancement and cine functional imaging signicantly improves diagnostic accuracy when characterising patients with possible ACS presenting to the emergency room with chest pain. Plein S, Greenwood JP, Ridgway JP, et al. Assessment of nonST-segment elevation acute coronary syndromes with cardiac magnetic resonance imaging. J Am Coll Cardiol 2004;44:2173e81. Kim RJ, Wu E, Rafael A, et al. The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction. N Engl J Med 2000;343:1445e53. Excellent description of the correlation between delayed gadolinium CMR and viability of myocardial tissue. Klein C, Nekolla SG, Bengel FM, et al. Assessment of myocardial viability with contrast-enhanced magnetic resonance imaging: comparison with positron emission tomography. Circulation 2002;105:162e7. Krittayaphong R, Maneesai A, Chaithiraphan V, et al. Comparison of diagnostic and prognostic value of different electrocardiographic criteria to delayed-enhancement magnetic resonance imaging for healed myocardial infarction. Am J Cardiol 2009;103:464e70. Kwong RY, Sattar H, Wu H, et al. Incidence and prognostic implication of unrecognized myocardial scar characterized by cardiac magnetic resonance in diabetic patients without clinical evidence of myocardial infarction. Circulation 2008;118:1011e20. Important study showing that even small areas of necrosis identied as hyperenhancement on DGE-CMR in diabetic patients, the majority of whom had no known myocardial infarction, predict a more than fourfold increased incidence of major adverse coronary events. Selvanayagam JB, Cheng AS, Jerosch-Herold M, et al. Effect of distal embolization on myocardial perfusion reserve after percutaneous coronary intervention: a quantitative magnetic resonance perfusion study. Circulation 2007;116:1458e64. Nijveldt R, Beek AM, Hirsch A, et al. Functional recovery after acute myocardial infarction: comparison between angiography, electrocardiography, and cardiovascular magnetic resonance measures of microvascular injury. J Am Coll Cardiol 2008;52:181e9. This comprehensive analysis of recovery of regional and global function after acute myocardial infarction strongly suggests that the presence of microvascular obstruction is the most powerful predictor, more powerful than transmural extent of infarction. Bleeker GB, Kaandorp TA, Lamb HJ, et al. Effect of posterolateral scar tissue on clinical and echocardiographic improvement after cardiac resynchronization therapy. Circulation 2006;113:969e76. Schmidt A, Azevedo CF, Cheng A, et al. Infarct tissue heterogeneity by magnetic resonance imaging identies enhanced cardiac arrhythmia susceptibility in patients with left ventricular dysfunction. Circulation 2007;115:2006e14. The rst study demonstrating that the extent of tissue heterogeneity at the infarct periphery imaged with CMR correlates with increased ventricular irritability by programmed electrical stimulation.

1592

Heart 2010;96:1586e1592. doi:10.1136/hrt.2008.152637