In 13 patients culprit lesions (6 × LAD, 2 × LCX, 5 × RCA) were identified by XRA (Fig. 1e+j) +/- intravascular ultrasound (IVUS). CE-MRI (fused with magnetic resonance angiography, Fig. 1c+h) correctly identified culprit lesions in 11 of 13 patients (sensitivity: 85%) and correctly classified the 3 patients without culprit lesions (specificity 100%). Contrast uptake in culprit lesions (Fig. 2a) as compared to overall vessel wall contrast uptake was 4-fold increased (50.7 ± 24.2 vs. 12.1 ± 7.7, p < 0.01) and 2-fold increased as compared to affected segments (19.2 ± 14.2, p < 0.01). Intra pair analysis (Fig. 2b) of the culprit lesion showed a 4-fold increase of the CNR as compared to the overall vessel wall contrast uptake (Ratio: 406 ± 123%), a 3-fold increase for the segments of the affected vessel (356 ± 155%) and a 2-fold increase for the affected segments (262 ± 92%). Subgroup analysis (Fig. 2c+d) revealed a significant higher contrast uptake of the culprit lesion (69.4 ± 20.5 vs. 31.2 ± 5.6, p = 0.01) and adjacent segments (30.7 ± 15.1 vs. 12.8 ± 5.1, p = 0.04) in the left coronary system (Fig. 2c) as compared to the right system (Fig. 2d). Non-affected segments showed no significant difference between the left and right system (3.5 ± 1.5 vs. 4.1 ± 1.3, p = 0.50). These findings are in concordance with a trend towards a higher TIMI Risk Score in patients with anterior MI (median: 21.5 (Range 16.1-35.9) vs. 1.6 (0.8-23.4), p = 0.06).