Stress Cardiovascular Magnetic Resonance Imaging for Stable Chest Pain

Stress Cardiovascular Magnetic Resonance Imaging for Stable Chest Pain

Stress cardiovascular magnetic resonance imaging is not as commonly used for evaluation of persons with stable chest pain as other modalities of non-invasive evaluation. Ricci and colleageus have reported a systematic review and meta-analysis on this aspect in JAMA Cardiology [1]. They evaluated 33 diagnostic studies including 7814 persons and 31 prognostic studies including 67,080 persons. The included studies were between 2002 and 2021.

The authors concluded that stress CMR had high diagnostic accuracy and had robust prognostication, especially when 3 Tesla MRI scanners were used. Myocardial ischemia and late gadolinium enhancement were associated with higher mortality and risk of major adverse cardiovascular events, which was  defined as the composite of myocardial infarction and cardiovascular death. Normal stress CMR was associated with a lower risk of MACE for at least a period of 3.5 years from the study.

According to 2021 AHA/ACC guidelines for the evaluation and diagnosis of chest pain, contraindications for stress CMR include glomerular filtration rate below 30 ml/min/1.73m², contraindications for administration of vasodilator, implanted devices which are not safe for CMR or producing artifact limiting scan quality or interpretation, significant claustrophobia, and use of caffeine within the past 12 hours [2].

CMR can accurately assess global and regional left and right ventricular function, as well as detect and localize myocardial ischemia and infarction. CMR is useful in determining myocardial viability. In addition CMR can detect myocardial edema and microvascular obstruction which will help in differentiating between acute and chronic infarcts and other causes of chest pain including myocarditis.

The 2021 AHA/ACC guidelines give Class I recommendation for stress CMR in patients with known obstructive coronary artery disease presenting with stable chest pain despite optimal medical therapy. For those with known extensive non-obstructive coronary artery disease with stable chest pain, they give a Class 2a recommendation for stress CMR evaluation [2].

References

1. Ricci F, Khanji MY, Bisaccia G, Cipriani A, Di Cesare A, Ceriello L, Mantini C, Zimarino M, Fedorowski A, Gallina S, Petersen SE, Bucciarelli-Ducci C. Diagnostic and Prognostic Value of Stress Cardiovascular Magnetic Resonance Imaging in Patients With Known or Suspected Coronary Artery Disease: A Systematic Review and Meta-analysis. JAMA Cardiol. 2023 Jun 7:e231290. doi: 10.1001/jamacardio.2023.1290. Epub ahead of print. PMID: 37285143; PMCID: PMC10248816.
2. Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O’Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Nov 30;144(22):e368-e454. doi: 10.1161/CIR.0000000000001029. Epub 2021 Oct 28. Erratum in: Circulation. 2021 Nov 30;144(22):e455. PMID: 34709879.