Abstract
The recently published 2019 guidelines on chronic coronary syndromes (CCS) focus on the need for noninvasive imaging modalities to accurately establish the diagnosis of coronary artery disease (CAD) and assess the risk of clinical scenario occurrence. Appropriate patient management should rely on controlling symptoms, improving prognosis, and guiding each therapeutic strategy as well as monitoring disease progress. Among the noninvasive imaging modalities, cardiovascular magnetic resonance (CMR) has gained broad acceptance in past years due to its unique features in providing a complete assessment of CAD through data on cardiac anatomy and function and myocardial viability, with high spatial and temporal resolution and without ionizing radiation. In detail, evaluation of the presence and extent of myocardial ischemia through stress CMR (S-CMR) has shown a high rule-in power in detecting functionally significant coronary artery stenosis in patients suspected of CCS. Moreover, S-CMR technique may add significant prognostic value, as demonstrated by different studies which have progressively evidenced the valuable power of this multiparametric imaging modality in predicting adverse cardiac events. The latest scientific progress supports a greater expansion of S-CMR with improvement of quantitative myocardial perfusion analysis, myocardial strain, and native mapping within the same examination. Although further study is warranted, these techniques, which are currently mostly restricted to the research field, are likely to become increasingly prevalent in the clinical setting with the scope of increasing accuracy in the selection of patients to be sent to invasive revascularization. This review investigates the diagnostic and prognostic role of S-CMR in the context of CAD, by analysing a strong, long-standing, scientific evidence together with an appraisal of new advanced techniques which may potentially enrich CAD management in the next future.
Highlights
Coronary artery disease (CAD) is a widespread clinical phenomenon associated with different clinical entities, which involves a large burden on the healthcare system with an increasing need for objective diagnostic tests to both confirm the diagnosis and assess the event risk [1,2,3,4]
Greenwood et al demonstrated a significantly higher sensitivity and negative predictive value of S-cardiovascular magnetic resonance (CMR) compared to single-photon emission computed tomography (SPECT) (86% vs. 66%, 90% vs. 79%, respectively, p < 0:0001), but with similar specificity and positive predictive values (83% vs. 82%, 77% vs. 71%, respectively, p = 0:916 and p = 0:061) for detecting significant coronary artery stenosis
Appropriate selection of patients who undergo Stress CMR (S-CMR) potentially provides further strength to its diagnostic accuracy, which has been widely validated in a large body of evidence and more recently demonstrated clinical effectiveness in direct guiding revascularization in the presence of myocardial ischemia
Summary
Coronary artery disease (CAD) is a widespread clinical phenomenon associated with different clinical entities, which involves a large burden on the healthcare system with an increasing need for objective diagnostic tests to both confirm the diagnosis and assess the event risk [1,2,3,4]. In 2019, the European Society of Cardiology (ESC) published the guidelines on the diagnosis and management of chronic coronary syndromes (CCS), which represent a relevant step by introducing innovative changes mostly in the diagnostic workup of suspected obstructive CAD. Noninvasive imaging methods, either functional tests or anatomical imaging, represent indispensable tools for appropriate management of patients with known or suspected CAD, by providing adequate detection of the disease, guiding therapy, and predicting outcome. The possibility of a multiparametric approach in each S-CMR study, from reproducible evaluation of cardiac function and scar detection to an accurate definition of myocardial ischemia in hemodynamically relevant coronary stenosis and microvascular dysfunction, has made S-CMR an appealing noninvasive modality for comprehensive assessment of CAD
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