Laurynas Miščikas¹, Martynas Bučnius¹, Tomas Lapinskas²

¹ Faculty of Medicine, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania

² Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania

Introduction. Cardiac magnetic resonance (CMR) imaging is widely used in clinical practice worldwide. The ability to evaluate comprehensively the global and regional systolic ventricular function, characterize the structure of the myocardium, and identify pathologically altered tissues gives a unique value to this imaging modality. Although echocardiography due to its availability remains the most common investigative technique to identify heart disease, CMR is gaining more evidence, and has been included into recent guidelines for the diagnosis and treatment of different origin heart diseases. Our review aims to perform a systematic summary of the CMR representation in the guidelines of the European Society of Cardiology (ESC).

Methods. Starting from the year 2010, twenty-five ESC guidelines have been overviewed (listed on the ESC website: https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines) for the terms ”MRI“, ”CMR“, ”MR“, and ”magnetic“. The order of the guidelines starts from the most recent to the oldest. Not imaging-related guidelines were not included in our review. Furthermore, the class of recommendation and level of evidence were obtained (Table 1 and Table 2), as well as the main CMR-related conclusions.

Results. Fifteen of the 25 guidelines (60%) contained specific CMR using recommendations. Nine ESC guidelines (36%) mention and describe the potential benefits of CMR but do not provide the specific recommendation. One guideline (4%, ”2010 Focused update of ESC Guidelines on device therapy in heart failure“) do not mention CMR at all. The 15 guidelines with specific recommendations regarding the use of CMR contain following classes of recommendation: 31 class I, 13 class IIa, 15 class IIb, and 4 class III. Most of the recommendations have evidence level C (40/63; 63.5%), followed by level B (21/63; 33.3%) and level A (2/63; 3.2%).

Conclusions. CMR has become an important imaging tool with important value for the diagnosis and management of cardiovascular disease. While not all ESC guidelines include clear recommendations for CMR application, the usage of CMR is discussed in the large majority of the guidelines.

Keywords: Cardiac magnetic resonance; Magnetic resonance imaging; ESC Guidelines; Cardiology; Radiology.

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Medical Sciences 2020 Vol. 8 (16), p. 20-36!

!

The role of cardiac magnetic resonance: European society of

cardiology guidelines review!

Laurynas Miščikas

1

, Martynas Bučnius

1

, Tomas Lapinskas

2

1

Faculty of Medicine, Medical Academy, Lithuanian University of Health Sciences, Kaunas,

Lithuania!

2

Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences,

Kaunas, Lithuania

Introduction. Cardiac magnetic resonance (CMR) imaging is widely used in clinical practice worldwide.

The ability to evaluate comprehensively the global and regional systolic ventricular function, characterize

the structure of the myocardium, and identify pathologically altered tissues gives a unique value to this

imaging modality. Although echocardiography due to its availability remains the most common

investigative technique to identify heart disease, CMR is gaining more evidence, and has been included

into recent guidelines for the diagnosis and treatment of different origin heart diseases. Our review aims

to perform a systematic summary of the CMR representation in the guidelines of the European Society of

Cardiology (ESC).

Methods. Starting from the year 2010, twenty-five ESC guidelines have been overviewed (listed on the

ESC website: https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines) for the terms ”MRI“,

”CMR“, ”MR“, and ”magnetic“. The order of the guidelines starts from the most recent to the oldest. Not

imaging-related guidelines were not included in our review. Furthermore, the class of recommendation and

level of evidence were obtained (Table 1 and Table 2), as well as the main CMR-related conclusions.

Results. Fifteen of the 25 guidelines (60%) contained specific CMR using recommendations. Nine ESC

guidelines (36%) mention and describe the potential benefits of CMR but do not provide the specific

recommendation. One guideline (4%, ”2010 Focused update of ESC Guidelines on device therapy in heart

failure“) do not mention CMR at all. The 15 guidelines with specific recommendations regarding the use

of CMR contain following classes of recommendation: 31 class I, 13 class IIa, 15 class IIb, and 4 class III.

Most of the recommendations have evidence level C (40/63; 63.5%), followed by level B (21/63; 33.3%)

and level A (2/63; 3.2%).

Conclusions. CMR has become an important imaging tool with important value for the diagnosis and

management of cardiovascular disease. While not all ESC guidelines include clear recommendations for

CMR application, the usage of CMR is discussed in the large majority of the guidelines.

!

Keywords: Cardiac magnetic resonance; Magnetic resonance imaging; ESC Guidelines; Cardiology;

Radiology.

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Introduction

Cardiovascular diseases (CVD) are the leading

cause of death worldwide, taking an estimated

17.9 million lives each year[1]. Early diagnosis

and management play the main role in patients

with suspected or confirmed CVD or individuals

with high-risk [1]. During the past two decades,

all imaging techniques rapidly evolved and have

been applied in subjects with mainly all CVD [2].

Previously the successful application of non-real

time imaging techniques has been limited due to

suboptimal image quality determined by heart

contractions and respiratory movements (non-

gated imaging)[3]. Nevertheless, evolving

imaging technology allowed the application of

highly reliable motion correction techniques,

resulting in images with excellent spatial and

temporal resolution [3]. Nowadays, the main

imaging tool due to its low cost, high temporal

resolution, and wide availability is

echocardiography [4], although, CMR is gaining

strong evidence. CMR allows detailed evaluation

of cardiac anatomy and function.– Moreover, it

enables to visualize the pathologically altered

tissues – the accumulation of gadolinium in the

myocardium provides a unique opportunity to

image changes in myocardial structure, such as

fibrosis, scar or infiltration [7]. The list of most

common indications for CMR contains

myocardial and pericardial inflammation

(myocarditis and pericarditis), ischemic heart

disease, cardiomyopathies, valvular heart disease

as well as diagnosis and surveillance of rare

diseases such as amyloidosis, sarcoidosis or

congenital heart disease [5, 6]. CMR usefulness

has been concluded into recent European Society

of Cardiology (ESC) guidelines for the diagnosis

and treatment of different heart diseases [7].

Methods

Starting from the year 2010, twenty-five ESC

guidelines were reviewed (available on the ESC

website -

https://www.escardio.org/Guidelines/Clinical-

Practice-Guidelines) for the terms ”MRI“,

”CMR“, ”MR“, and ”magnetic“. The order of the

guidelines starts from the most recent to the

oldest. The class of recommendation and level of

evidence were obtained (Tables 1 and 2), as well

as the main CMR-related conclusions.

Table 1. Class of recommendation

Class of

recommendation

Definition

Suggested wording to use

Class I

Evidence or general agreement that a given

treatment or procedure is beneficial, useful,

effective.

Is recommended

Class II

Conflicting evidence and a divergence of opinion

about usefulness/efficacy of the given treatment or

procedure.

Class IIa

Weight of evidence/opinion is in favor of

usefulness/efficacy.

Should be considered

Class IIb

Usefulness/efficacy is less well established by

evidence/opinion.

May be considered

Class III

Evidence or general agreement that the given

treatment or procedure is not useful/effective, and is

some cases may be harmful.

Is not recommended

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Table 2. Level of evidence

Level of evidence A

Data derived from multiple randomized clinical trials or meta-analysis.

Level of evidence B

Data derived from a single randomized clinical trial or large non-randomized

studies.

Level of evidence C

Consensus or opinion of the experts and/or small studies, retrospective studies,

registries.

Results

2019 ESC Guidelines on diabetes, pre-diabetes,

and cardiovascular diseases developed in

collaboration with the EASD [8]

Patients with altered glucose metabolism are at

higher risk for developing cardiac disease. Early

risk stratification by the use of laboratory testing,

electrocardiogram (ECG), and imaging may be

beneficial for these patients. In addition to

conventional risk stratification, CMR has

demonstrated that patients with diabetes and

without coronary artery disease (CAD) might have

diffuse myocardial fibrosis, which may lead to LV

systolic and diastolic dysfunction. However, the

prognostic value of CMR needs further

investigation in prospective studies. Another

possible complication of diabetes mellitus is lower

extremity artery disease (LEAD). In this case,

computed tomography (CT) and/or magnetic

resonance angiography (MRA) is recommended

before scheduled revascularization. Specific

recommendations are given in Table 3.

2019 ESC Guidelines for the diagnosis and

management of acute pulmonary embolism

developed in collaboration with the European

Respiratory Society (ERS) [9]

MRA is considered as a promising imaging

technique in diagnosing pulmonary artery

embolism, and has been evaluated in several

extensive studies. However, it has been concluded

that MRA is not yet suitable for clinical decision-

making due to its lower sensitivity, high number of

inconclusive scans, and low availability in

emergency departments. Specific recommendations

are provided in Table 3.

2019 ESC Guidelines for the management of

patients with supraventricular tachycardia [10]

Tachycardia-induced cardiomyopathy (TCM) is a

reversible cause of heart failure (HF) and dilated

cardiomyopathy, and should be considered in all

patients with new-onset of left ventricular

dysfunction. In suspected TCM cases, CMR should

be considered to exclude intrinsic myocardial

structural abnormalities. However, there are no

specific recommendations regarding the application

of CMR in these guidelines.

2019 ESC Guidelines for the diagnosis and

management of chronic coronary syndromes

[11]

In initial decision-making, patients with suspected

CAD and inconclusive ECG are advised to be tested

using CMR as it can provide an important

information on cardiac anatomy and global as well

as regional myocardial performance. Functional

non-invasive imaging, including stress CMR,

allows to detect myocardial ischemia through

inducible regional wall motion abnormalities.

Compared to the 2013 guidelines, there are few new

important recommendations regarding the use of

CMR. First, non-invasive functional test is

recommended as the initial test for diagnosing CAD

in symptomatic patients when CAD cannot be

excluded by clinical assessment alone. Second, the

use of non-invasive functional imaging is

recommended in patients in whom computed

tomography coronary angiography (CTCA)

demonstrated uncertain functional significance

CAD. In addition, there are some changes in

diagnostic workup in patients with suspected

coronary microvascular angina. Recent guidelines

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ascertain that non-invasive assessment of coronary

flow reserve (CFR) includes not only transthoracic

Doppler of the left anterior descending (LAD)

artery but also CMR and positron emission

tomography (PET). In assessing the risk of adverse

cardiovascular events, it is advised to use one of the

functional imaging modalities, including stress

imaging. Inducible perfusion defects in 2 of 16

segments (myocardial perfusion CMR study) or

more than 3 Dobutamine-induced dysfunctional

segments detected using stress CMR is a sign of

high risk. Patients with a long-standing diagnosis of

chronic coronary syndromes (CCS) should be

examined regularly, and in the presence of

worsening symptoms, it is recommended to repeat

functional testing. In patients with severe valvular

disease, the routine use of stress CMR is not

recommended due to lower diagnostic value and

potential risk. Specific recommendations are given

in Table 3.

Table 3. Recommendations for CMR in 2019 ESC Guidelines

Class

Level

2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases

CTCA or functional imaging (radionuclide myocardial perfusion imaging, stress

cardiac magnetic resonance imaging, or exercise or pharmacological stress

echocardiography) may be considered in asymptomatic patients with diabetes mellitus

(DM) for screening of CAD.

IIb

B

Detection of atherosclerotic plaque of carotid or femoral arteries by CT, or magnetic

resonance imaging, may be considered as a risk modifier in patients with DM at

moderate or high risk CV.

IIb

B

CT angiography or magnetic resonance angiography is indicated in case of lower

extremity artery disease (LEAD) when revascularization is considered.

I

C

2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism

MRA is not recommended for ruling out pulmonary embolism.

III

A

2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes

Risk stratification, preferably using stress imaging or coronary CTA, or

alternatively exercise stress ECG (if significant exercise can be performed and the

ECG is amenable to the identification of ischaemic changes), is recommended in

patients with suspected or newly diagnosed CAD.

I

B

If coronary CTA is available for event risk stratification, additional stress imaging

should be performed before the referral of a patient with few/no symptoms for

invasive coronary angiography.

IIa

B

In the initial diagnostic management, CMR may be considered in patients with an

inconclusive echocardiographic test.

IIb

C

Non-invasive functional imaging for myocardial ischaemia or coronary CTA is

recommended as the initial test for diagnosing CAD in symptomatic patients in whom

obstructive CAD cannot be excluded by clinical assessment alone.

I

B

Functional imaging for myocardial ischaemia is recommended if coronary CTA has

shown CAD of uncertain functional significance or is not diagnostic.

I

B

In high-risk asymptomatic adults (with diabetes, a strong family history of CAD, or

when previous risk-assessment tests suggest a high risk of CAD), functional imaging

or coronary CTA may be considered for cardiovascular risk assessment.

IIb

C

In low-risk non-diabetic asymptomatic adults, coronary CTA or functional imaging for

ischaemia are not indicated for further diagnostic assessment.

III

C

In people with long-standing diagnosis of chronic coronary syndrome, risk

stratification is recommended for patients with new or worsening symptom levels,

I

B

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preferably using stress imaging or, alternatively, exercise stress ECG.

Transthoracic Doppler of the LAD, CMR, and PET may be considered for non-invasive

assessment of coronary flow reserve.

IIb

B

In asymptomatic adults (age >40 years) with diabetes, functional imaging or

coronary CTA may be considered for advanced cardiovascular risk assessment.

IIb

B

In severe valvular heart disease, stress testing should not be routinely used to detect

CAD because of the low diagnostic yield and potential risks

III

C

2018 ESC/ESH Clinical Practice Guidelines for

the Management of Arterial Hypertension [12]

In patients with hypertension-mediated organ

damage, CMR has demonstrated higher sensitivity

to detect treatment-induced left ventricular

hypertrophy changes when compared with

echocardiography. There is still missing data about

the prognostic value of the hypertophic changes and

no specific recommendation regarding CMR.

2018 Fourth universal definition of myocardial

infarction [13]

CMR gives an ability to assess bi-ventricular

function, myocardial perfusion, and scar using late

gadolinium enhancement (LGE), which is a marker

of prior myocardial infarction (MI). CMR can also

be used to detect other myocardial injury features,

such as the presence and extent of myocardial

edema, myocardial salvage index, microvascular

obstruction, intramyocardial hemorrhage or infarct

size that have prognostic value. In difficult cases of

acute MI, when coronary artery obstruction is not

detected, CMR can help to diagnose alternative

conditions such as myocarditis, Takotsubo

syndrome, embolic infarction, or MI with

spontaneous coronary artery recanalization. Despite

clear benefits of CMR in such clinical situation,

document does not provide clear statement for the

CMR application..

2018 ESC Guidelines for the diagnosis and

management of syncope [14]

CMR imaging has no specific recommendation in

the diagnosis or management of syncope. It has only

additional advice that CMR or CT should be

considered in selected patients presenting with

syncope and suspected structural heart disease

when echocardiography is non-diagnostic.

2018 ESC/EACTS Guidelines on Myocardial

Revascularization [15]

For the assessment of myocardial viability and

ischemia, CMR may be performed in selected

patients with HF and CAD that are more likely to

benefit from myocardial revascularization. Specific

recommendations are given in Table 4.

2018 ESC Guidelines for the management of

cardiovascular diseases during pregnancy [16]

The guidelines conclude that CMR should be

performed only in cases when other non-invasive

diagnostic imaging is not sufficient to substantiate

the diagnosis. In addition, the usage of gadolinium-

based contrast agent should be avoided if possible,

especially in the first trimester of pregnancy.

Specific recommendations are given in Table 4.

2017 ESC/EACTS Guidelines for the

management of valvular heart disease [17]

These guidelines recognize CMR as a possible

diagnostic tool for evaluating the degree of

valvular, particularly regurgitant lesions, and

assessing ventricular volumes, systolic function,

abnormalities of the ascending aorta, and

myocardial fibrosis in patients with an inadequate

echocardiographic quality or inconclusive results.

In aortic regurgitation, CMR can be used to quantify

the regurgitant volume and regurgitant fraction and

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changes during follow-up, but clinical decision-

making for surgical intervention is recommended to

be based on CT. For dilated ascending aorta (>40

mm), it is recommended to perform CT or MR

angiography. However, there are no specific

recommendations regarding CMR usage in this

document.

2017 ESC Guidelines on the Diagnosis and

Treatment of Peripheral Arterial Diseases [18]

MRA may be a helpful diagnostic tool for

peripheral artery imaging, especially in patients

with mild to moderate chronic kidney disease.

However, due to lower resolution and susceptibility

to artifacts, the use of MRA is still limited. There

are specific recommendations regarding the use of

MRA in this guideline. In carotid artery disease,

patients with asymptomatic stenoses can be

identified using MRA or duplex ultrasound (DUS).

Morphological features associated with increased

risk of stroke are intraplaque hemorrhage and lipid-

rich necrotic core. In clinical cases with a high-risk

of renal artery disease, it is recommended to

perform DUS followed by MRA to establish the

diagnosis. In addition, MRA provides an excellent

characterization of renal arteries, the surrounding

vessels, renal mass, and even renal excretion

function. MRA (or DUS, or CTA) enables to

evaluate the lesions of lower extremity artery

disease before revascularization. Specific

recommendations are given in Table 4.

2017 ESC Guidelines for the management of

acute myocardial infarction in patients

presenting with ST-segment elevation [19]

Routine echocardiography after a primary

percutaneous coronary intervention is

recommended to evaluate ventricular function at

rest and exclude early post-infarction mechanical

complications. When echocardiography is

inconclusive, CMR may be a good alternative. In

post-MI patients, LGE-CMR imaging has a high

diagnostic accuracy for assessing the transmural

myocardial scar. In addition, the presence of

dysfunctional viable myocardium by LGE is an

independent predictor of mortality. It is considered

that performing CMR in 2 weeks after myocardial

infarction with non-obstructive coronary arteries

can increase the accuracy of its etiology

identification. Specific recommendations are given

in Table 4.

Table 4. Recommendations for MRI in 2017-2018 ESC Guidelines

Class

Level

2018 ESC/EACTS Guidelines on Myocardial Revascularization

Non-invasive stress imaging (CMR, stress echocardiography, SPECT, or PET) may be

considered for the assessment of myocardial ischemia and viability in patients with heart

failure (HF) and CAD (considered suitable for coronary revascularization) before the

decision on revascularization.

IIb

B

2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy.

MRI (without gadolinium) should be considered if echocardiography is insufficient for

a definite diagnosis.

IIa

C

Imaging of the entire aorta (CT/MRI) is recommended before pregnancy in patients with

a genetically proven aortic syndrome or known aortic disease.

I

C

For imaging of pregnant women with dilatation of the distal ascending aorta, aortic arch,

or descending aorta, MRI (without gadolinium) is recommended.

I

C

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases

Duplex ultrasound (DUS) (as first-line), CTA and/or MRA are recommended for

evaluating the extent and severity of extracranial carotid stenoses.

I

B

When carotid artery stenting (CAS) is being considered, it is recommended that any

DUS study be followed either by MRA or CTA to evaluate the aortic arch, as well as

the extra- and intracranial circulation.

I

B

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When carotid endarterectomy (CEA) is considered, it is recommended that the DUS

stenosis estimation be corroborated either by MRA or CTA (or by a repeat DUS study

performed in an expert vascular laboratory).

I

C

DUS (as first-line), CTA and MRA are recommended imaging modalities to establish a

diagnosis of renal artery disease

I

B

DUS and/or CTA and/or MRA are indicated for anatomical characterization of lower

extremity artery disease (LEAD) lesions and guidance for optimal revascularization

strategy.

I

C

2017 ESC Guidelines for the management of acute MI in patients presenting with ST-segment

elevation

When echocardiography is suboptimal/inconclusive (during hospital stay), an

alternative imaging method (CMR preferably) should be considered.

IIa

C

Either stress echo, CMR, SPECT, or PET may be used to assess myocardial

ischaemia and viability, including in multivessel CAD.

IIb

C

When echo is suboptimal or inconclusive (after discharge), alternative imaging

methods (CMR preferably) should be considered to assess LV function.

IIa

C

2016 ESC Position Paper on cancer treatments

and cardiovascular toxicity [20]

CMR has no specific recommendation, only that it

is a helpful tool to evaluate cardiac and extra cardiac

structures, left and right ventricle function. In

addition, CMR is an excellent test for the

comprehensive evaluation of cardiac masses and

infiltrative conditions. The use of unique tissue

characterization capabilities of CMR (e.g.,

inflammation and edema) is dependent on the

acceptance of T2 and T1 mapping and extracellular

volume fraction quantification.

2016 ESC Guidelines for the diagnosis and

treatment of acute and chronic heart failure [21]

CMR is the best alternative diagnostic imaging

method for echocardiography. It is a gold standard

to assess ventricular volumes, myocardial mass, and

ejection fraction (EF) of both ventricles. Also, CMR

is the method of choice in complex congenital heart

diseases and as well as myocardial fibrosis using

LGE. Besides, CMR is recommended for

myocardial tissue characterization in suspected

cases like myocarditis, sarcoidosis, amyloidosis,

Chagas disease, Fabry-Anderson disease, left

ventricular non-compaction cardiomyopathy, and

hemochromatosis. Specific recommendations are

given in Table 5.

2015 ESC Guidelines for the management of

infective endocarditis [22]

The use of CMR is described in the infective

endocarditis complications management. One of the

complications is myocarditis. To assess myocardial

involvement transthoracic echocardiography (TTE)

or cardiac CMR can be used. There are some

specific recommendations regarding the use of

cranial MRA in assessing neurological

complications, but it is not the subject of this

review.

2015 ESC Guidelines for the diagnosis and

management of pericardial diseases [23]

CMR allows the visualization and characterization

of the pericardium and other heart tissues in patients

with pericardial disease as well as to identify the

consequences of pericardial abnormalities on

cardiac function and filling parameters. Because of

these advantages, CMR is considered the preferred

imaging modality to assess pericardial diseases. In

the case of myopericarditis, CMR is the modality of

choice in confirming the involvement of

myocardium. In addition, CMR provides the

opportunity to detect local pericardial effusion,

observe its thickening or additional masses.

Although echocardiography is still the primary

diagnostic tool, CMR and CT can be helpful in

some situations diagnosing pericardial effusion or

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constrictive pericarditis. Specific recommendations

are given in Table 5.

2015 ESC Guidelines for the management of

patients with ventricular arrhythmias and the

prevention of sudden cardiac death [24]

Recent technological advances in CMR enables

precise quantification of cardiac chamber

volumes,myocardial mass and ventricular function.

It is of high diagnostic value in patients with

arrhythmogenic right ventricular cardiomyopathy,

and in some other situations when

echocardiography is not conclusive or functional

testing is required. CMR has been recognized as a

prognostic tool in athletes with abnormal ECG and

in patients with inflammatory heart disease.

Specific recommendations are given in Table 5.

2015 ESC/ERS Guidelines for the diagnosis and

treatment of pulmonary hypertension [25]

In this guideline, CMR is recognized as one of the

diagnostic tools in evaluating pulmonary

hypertension and its consequences. Due to its

capability to assess right ventricular size, function,

and blood flow, CMR provides useful prognostic

information in patients with pulmonary arterial

hypertension (PAH). However, there are no specific

recommendations.

2015 ESC Guidelines for the management of

acute coronary syndromes in patients presenting

without persistent ST-segment elevation [26]

CMR can be helpful in detecting changes in

myocardial perfusion and regional wall motion

abnormalities. It has been reported that a normal

stress CMR has a high negative predictive value in

patients with acute chest pain[26]. In addition,

CMR allows differentiation between old scar tissue

and recent myocardial infarction. CMR is

recommended for the differential diagnosis between

MI and myocarditis or Takotsubo cardiomyopathy.

These guidelines conclude only non-specific

recommendations for stress imaging.

Recommendations are given in Table 5.

Table 5. Recommendations for CMR in 2015-2016 ESC guidelines

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure

CMR is recommended for the assessment of myocardial structure and function

(including right heart) in subjects with poor acoustic window and patients with

complex congenital heart diseases (taking account of contra-indications to CMR).

I

C

CMR with LGE should be considered in patients with dilated cardiomyopathy in order

to distinguish between ischaemic and non-ischaemic damage in case of equivocal

clinical and other imaging data (taking account of cautions/contra-indications to CMR).

IIa

C

CMR is recommended for the characterization of myocardial tissue in case of suspected

myocarditis, amyloidosis, sarcoidosis, Chagas or Fabry disease, non-compaction

cardiomyopathy, haemochromatosis (taking account of contra-indications to CMR).

I

C

Non-invasive stress imaging (CMR, stress echocardiography, SPECT, PET) may be

considered for the assessment of myocardial ischemia and viability in patients with HF

and CAD before the decision on revascularization.

IIb

B

2015 ESC Guidelines for the diagnosis and management of pericardial diseases

CT and/or CMR are recommended as second-level testing for diagnostic workup in

pericarditis.

I

C

Cardiac magnetic resonance is recommended for the confirmation of myocardial

involvement in suspected myopericarditis.

I

B

CT or CMR should be considered in suspected cases of loculated pericardial effusion,

pericardial thickening and masses, as well as associated chest abnormalities.

IIa

C

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In constrictive pericarditis, CT and/or CMR are indicated as second-level imaging

techniques to assess calcifications (CT), pericardial thickness, degree and extension of

pericardial involvement.

I

C

Empiric anti-inflammatory therapy may be considered in cases with transient or new

diagnosis of constriction with concomitant evidence of pericardial inflammation (i.e.

CRP elevation or pericardial enhancement on CT/CMR).

IIb

C

2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the

prevention of sudden cardiac death

Pharmacological stress testing plus imaging modality is recommended to detect silent

ischaemia in patients with VAs who have an intermediate probability of having CAD

by age or symptoms and are physically unable to perform a symptom-limited exercise

test.

I

B

CMR/CT should be considered in patients with VAs when echocardiography does not

provide accurate assessment of LV and RV function or evaluation of structural changes.

IIa

B

CT or CMR should be considered in suspected cases of loculated pericardial effusion,

pericardial thickening and masses, as well as associated chest abnormalities.

IIa

C

Demonstration of persistent myocardial inflammatory infiltrates by

immunohistological evidence and/or abnormal localized fibrosis by CMR after acute

myocarditis may be considered as an additional indicator of increased risk of sudden

cardiac death in inflammatory heart disease.

IIb

C

Upon identification of ECG abnormalities suggestive of structural heart disease,

echocardiography and/or CMR imaging is recommended in athletes.

I

C

2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting

without persistent ST-segment elevation

In patients with no recurrence of chest pain, normal ECG findings and normal levels

of cardiac troponin (preferably high-sensitivity), but suspected acute coronary

syndrome, a non-invasive stress test (preferably with imaging) for inducible

ischaemia is recommended before deciding on an invasive strategy.

I

A

2014 ESC guidelines on diagnosis and

management of hypertrophic cardiomyopathy

[27]

Numerous parameters provide a semi-quantitative

score of left ventricle hypertrophy (LVH).

However, for diagnostic purposes, the single most

relevant setting, measured by any imaging

technique, is the maximum LV wall thickness at any

level ≥15 mm, and ≥13 mm in first-degree relatives.

Similar to echocardiography, CMR provides

information on ventricular function and

morphology. It helps to differentiate HCM from

hypertensive heart disease and establish the

diagnosis of HCM in patients with inadequate

echocardiography acoustic windows, poorly

visualized LV apex, anterolateral wall, or RV.

Moreover, CMR imaging is superior to TTE in the

assessment of LV mass, detection of LV apical and

anterolateral hypertrophy, aneurysms, thrombi,

myocardial crypts, and papillary muscle

abnormalities.

CMR is helpful before surgical myectomy or

alcohol septal ablation to assess myocardial fibrosis

and hypertrophy distribution, and may be

considered during follow-up in stable patients or

patients with progressive disease. Specific

recommendations are given in Table 6.

2014 ESC/ESA Guidelines on non-cardiac

surgery: cardiovascular assessment and

management [28]

LV function can be assessed before non-cardiac

surgery in high-risk surgery (IIb, C). This can be

performed by echocardiography, multislice CT,

CMR, radionuclide ventriculography, and gated

single-photon emission computed tomography

(SPECT), all with comparable accuracy. Specific

recommendations are given in Table 6.

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2014 ESC guidelines on the diagnosis and

treatment of aortic diseases [29]

CMR is a valuable imaging method for the full

range of aortic disease. CT and CMR are superior

imaging tools to transoesophageal

echocardiography (TOE) for the assessment of

acute aortic dissection. However, CMR is

considered the leading technique for diagnosis, with

a reported sensitivity and specificity of 98%. It

demonstrates the extent of the disease and depicts

the distal ascending aorta, aortic arch, and proximal

coronary arteries and their involvement in the

dissecting process.

Also, CMR can be a valuable imaging tool to

differentiate intramural hematoma (IMH) from

atherosclerotic thickening or thrombus. After

thoracic endovascular aortic repair (TEVAR)

surgery, patients have to be followed up in the long

term to detect complications using CT or MRI. If

stent-graft composites are not paramagnetic, the

best alternative to detect pseudoaneurysm,

endoleaks, and stent-graft material-related

complications are CMR and chest X-ray

combination. In cases with the bicuspid aortic valve

or inaccurate assessment by TTE, CMR is

preferable to visualize the aortic root and ascending

aorta. If aortic diameter using echocardiography is

>50 mm or an increase >3 mm per year, CT or CMR

is the pre-operative gold standard to adequately

visualize the entire aorta, identify the affected parts,

and to asses post-operative enlargement rates

during annual follow-up.

CMR should be an alternative tool in cases for

cardiovascular risk assessment in Turner's

syndrome as well as for the entire aorta evaluation

in suspected extracranial giant cell or Takayasu

arteritis. Specific recommendations are given in

Table 6.

2013 ESC Guidelines on cardiac pacing and

cardiac resynchronization therapy [30]

This guideline focus on the safe use of CMR in

patients with implanted cardiac devices. Potential

adverse effects of CMR on implanted cardiac

devices can be radiofrequency-induced heating of

the lead tips, pacing inhibition, asynchronous

pacing, loss of programmed data, and others. The

prevention of these events is qualified personnel,

thorough patient selection, and appropriate CMR

scanning parameters. Specific recommendations are

given in Table 6.

2010 ESC Guidelines for the management of

grown-up congenital heart disease [31]

Cardiac magnetic resonance imaging has become

increasingly important in patients with grown-up

congenital heart diseases. It enables excellent 3D

anatomical reconstruction, which is not restricted

by acoustic windows or body size. Moreover, it has

rapidly improved spatial and temporal resolution.

ESC recommendations have been published

separately for each grown-up congenital heart

disease [31]. CMR is mainly used for anomaly

detection and quantification, volumetric

parameters, both ventricles mass and function,

evaluation of RV outflow tract and conduits, same

as aorta, pulmonary arteries, systemic and

pulmonary veins, arteriovenous malformations and

collaterals. Moreover, it can quantify pulmonary

regurgitation, coronary anomalies, CAD, intra- and

extracardiac masses, and characterization of

myocardial tissue.

2010 Focused update of ESC Guidelines on

device therapy in heart failure [32]

CMR is not mentioned in this guideline.

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Table 6. Recommendations for MRI in 2013-2014 ESC guidelines

2014 ESC guidelines on diagnosis and management of hypertrophic cardiomyopathy

It is recommended that CMR studies be performed and interpreted by teams

experienced in cardiac imaging and in the evaluation of heart muscle disease.

I

B

In the absence of contraindications, CMR with LGE is recommended in patients with

suspected HCM who have inadequate echocardiographic windows, in order to confirm

the diagnosis.

I

C

In the absence of contraindications, CMR with LGE should be considered in patients

fulfilling diagnostic criteria for HCM, to assess cardiac anatomy, ventricular function,

and the presence and extent of myocardial fibrosis.

IIa

B

CMR with LGE imaging should be considered in patients with suspected apical

hypertrophy or aneurysm.

IIa

C

CMR with LGE imaging should be considered in patients with suspected cardiac

amyloidosis.

IIa

C

CMR with LGE may be considered before septal alcohol ablation or myectomy, to assess

the extent and distribution of hypertrophy and myocardial fibrosis.

IIb

C

CMR may be considered every 5 years in clinically stable patients, or every 2–3 years in

patients with progressive disease.

IIb

C

2014 ESC guidelines on the diagnosis and treatment of aortic diseases

In stable patients with a suspicion of acute aortic syndrome, CMR is recommended (or

should be considered) according to local availability and expertise.

I

C

In case of initially negative imaging with persistence of suspicion of acute aortic

syndrome, repetitive imaging (CT or CMR) is recommended.

I

C

In case of uncomplicated Type B aortic dissection treated medically, repeated imaging

(CT or CMR) during the first days is recommended.

I

C

In uncomplicated Type B intramural hematoma, repetitive imaging (CMR/CT) is

indicated.

I

C

In uncomplicated Type B penetrating aortic ulcer, repetitive imaging (CMR/CT) is

indicated.

I

C

CMR or CT is indicated in patients with bicuspid aortic valve when the morphology of

the aortic root and the ascending aorta cannot be accurately assessed by TTE.

I

C

In the case of aortic diameter >50 mm or an increase >3 mm/year measured by

echocardiography, confirmation of the measurement is indicated, using another imaging

modality (CT or CMR).

I

C

CT or CMR is recommended to confirm the diagnosis of chronic aortic dissection.

I

C

For follow-up after (T)EVAR in young patients, CMR should be preferred to CT for

magnetic resonance-compatible stent grafts, to reduce radiation exposure.

IIa

C

2014 ESC/ESA Guidelines on non-cardiac surgery

Imaging stress testing is recommended before high-risk surgery in patients with more

than two clinical risk factors and poor functional capacity (<4 METs).

I

C

Imaging stress testing may be considered before high- or intermediate-risk surgery in

patients with one or two clinical risk factors and poor functional capacity (<4 METs).

IIb

C

Imaging stress testing is not recommended before low-risk surgery, regardless of the

patient’s clinical risk.

III

C

2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy

In patients with conventional cardiac devices, MR at 1.5 T can be performed with a low

risk of complications if appropriate precautions are taken (see additional advice).

IIb

B

In patients with MR-conditional PM systems, MR at 1.5 T can be done safely following

manufacturer instructions.

IIa

B

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Discussion

This systematic review shows that CMR has been

recognized as useful imaging modality and the role

of CMR in clinical practice has been increasing. It

has the ability to evaluate cardiac anatomy, wall

motion, chamber volumes, flow velocity and tissue

changes with high diagnostic accuracy. Due to these

features, CMR is an irreplaceable imaging tool in

some clinical situations [33]. The most important

indications in ESC Guidelines remains risk

evaluation in suspected CAD, management of

myocarditis and cardiomyopathies as well as

assessment of myocardium viability [6]. There are

a number of magnetic resonance techniques and

sequences, so it is essential to perceive their value

in different clinical applications. For example, dark-

blood MR imaging is used to assess vascular

abnormalities, cine cardiac MRI to evaluate

ventricular volumes and function, LGE-CMR to

detect scarring of myocardium, stress CMR to

assess ventricular, valvular or ischemic

abnormalities [34,35]. Since CMR is considered to

be a promising imaging modality, new sequences

such as fingerprinting, 4D-flow or diffusor tensor

imaging are being introduced and further clinical

trials are needed to prove its benefits [36]. Despite

being a valuable imaging technique, CMR still has

relatively low accessibility, high costs and lack of

trained personnel that limits its use [37].

It is important to mention that our study is limited

to ESC Guidelines and we discuss only

recommendations given in there. There are some

evidence that CMR is useful in more clinical

situations such as detecting cardiac sarcoidosis,

systematic lupus erythematosus, cardiotoxicity and

other [36,38]. However, it is not the object of our

study.

Conclusions

Cardiac magnetic resonance has become an

important part of cardiovascular disease

management. The use of CMR is discussed in the

vast majority of ESC Guidelines and all

recommendations regarding its use are collected in

the tables above (Tables 3-6). Cardiac magnetic

resonance remains the imaging modality of interest

and further investigations are being held to

determine its possible diagnostic benefits.

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