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Stress CMR
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Indications and purpose of the scan
  • In patients with suspected coronary artery disease, first-pass perfusion CMR is a safe, fast, accurate and cost-efficient test for inducible myocardial ischemia.
Description
  • Cardiac images acquired during the inflow of an MRI contrast agent while administering a vasoactive agent allow for detecting regional perfusion deficits. It is typically combined with the assessment for myocardial scars and takes about 30 minutes.
Why CMR (Specific Advantages)
  • A CMR stress test alleviates the need for an echocardiogram or a nuclear scan for this indication and in many cases, invasive coronary angiograms can also be avoid.
  • There is no ionizing radiation, sensitivity to breast or diaphragm attenuation or gender-based differences in accuracy 1. Because of its safety, stress CMR is especially useful in younger and in female patients.
Evidence
  • CE-MARC Study (752 patients): Stress CMR could safely be performed in all participants and had a better sensitivity and specificity (86.5/83.4%) than SPECT (66.5/82.6%) for detecting significant coronary artery stenosis 2.
  • MR-INFORM Study (918 patients): Stress CMR had a similar outcome as invasive FFR for guiding the indication for revascularization, but was associated with a significant reduction of invasive revascularization procedures 3.
Contraindications
  • Reasons to consider a test other than stress CMR include the presence of contraindications to MRI, and severe renal failure (eGFR<30).
Appropriateness

References
  1. Greenwood JP, Motwani M, Maredia N, Brown JM, Everett CC, Nixon J, Bijsterveld P, Dickinson CJ, Ball SG, Plein S. Comparison of Cardiovascular Magnetic Resonance and Single-Photon Emission Computed Tomography in Women with Suspected Coronary Artery Disease from the CE-MARC Trial. Circulation. 2013;
  2. Greenwood JP, Maredia N, Younger JF, Brown JM, Nixon J, Everett CC, Bijsterveld P, Ridgway JP, Radjenovic A, Dickinson CJ, Ball SG, Plein S. Cardiovascular magnetic resonance and single-photon emission computed tomography for diagnosis of coronary heart disease (CE-MARC): a prospective trial. Lancet. 2012;379:453–460.
  3. Nagel E. MR-INFORM: Stress Perfusion Imaging to Guide the Management of Patients with Stable Coronary Artery Disease. American College of Cardiology Sessions 2017. 
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