Table 4 Summary of clinical scenarios / diagnosis groups, where the AHA/ACC guidelines make recommendations regarding CMR

Suspected / stable coronary artery disease

 Noninvasive imaging to detect myocardial ischemia and viability is reasonable in heart failure and coronary artery disease

IIa

C

Heart failure [5, 6, 22]

 Noninvasive imaging (stress nuclear/positron emission tomography, CMR, or stress echocardiography), cardiac CT angiography, or cardiac catheterization, including coronary arteriography, is useful to establish etiology of chronic secondary MR (stages B to D) and/or to assess myocardial viability, which in turn may influence management of functional MR.

I

C

Valve disease [7, 23]

 Pharmacological stress with CMR can be useful for patients with an intermediate to high pretest probability of obstructive ischemic heart disease, who have an uninterpretable ECG and at least moderate physical functioning or no disabling comorbidity.

IIa

B

Stable CAD [8]

 Pharmacological stress CMR is reasonable for patients with an intermediate to high pretest probability of ischemic heart disease, who are incapable of at least moderate physical functioning or have disabling comorbidity.

IIa

B

Stable CAD [8]

 Echocardiography, radionuclide imaging, CMR, and cardiac CT are not recommended for routine assessment of LV function in patients with a normal ECG, no history of myocardial infarction, no symptoms or signs suggestive of heart failure, and no complex ventricular arrhythmias.

III

C

Stable CAD [8]

 Routine reassessment (<1 year) of LV function with technologies such as echocardiography, radionuclide imaging, CMR, or cardiac CT is not recommended in patients with no change in clinical status and for whom no change in therapy is contemplated.

III

C

Stable CAD [8]

 CMR with pharmacological stress is reasonable for risk assessment in patients with stable ischemic heart disease who are able to exercise to an adequate workload but have an uninterpretable ECG.

IIa

B

Stable CAD [8]

 Pharmacological stress imaging (nuclear MPI, echocardiography, or CMR) or CCTA is not recommended for risk assessment in patients with stable ischemic heart disease who are able to exercise to an adequate workload and have an interpretable ECG.

III

C

Stable CAD [8]

 Pharmacological stress CMR is reasonable for risk assessment in patients with stable ischemic heart disease who are unable to exercise to an adequate workload regardless of interpretability of ECG.

IIa

B

Stable CAD [8]

Acute coronary syndrome

 Imaging with ventriculography, echocardiography, or magnetic resonance imaging should be performed to confirm or exclude the diagnosis of stress (Takotsubo) cardiomyopathy.

I

B

NSTEMI [26]

 Before coronary revascularization

 Viability assessment is reasonable before revascularization in heart failure patients with coronary artery disease

IIa

B

Heart failure [5, 6, 22]

 Either exercise or pharmacological stress with imaging (nuclear MPI, echocardiography, or CMR) is recommended for risk assessment in patients with stable ischemic heart disease, who are being considered for revascularization of known coronary stenosis of unclear physiological significance.

I

B

Stable CAD [8]

Heart failure

  Radionuclide ventriculography or MRI can be useful to assess LVEF and volume

IIa

C

Heart failure [5, 6, 22]

  MRI is reasonable when assessing myocardial infiltration or scar

IIa

B

Heart failure [5, 6, 22]

Ventricular arrhythmia

 MRI, cardiac computed tomography (CT), or radionuclide angiography can be useful in patients with ventricular arrhythmias when echocardiography does not provide accurate assessment of LV and RV function and/or evaluation of structural changes.

IIa

B

Ventricular arrhythmias [35]

Hypertrophic cardiomyopathy

 CMR imaging is indicated in patients with suspected HCM when echocardiography is inconclusive for diagnosis.

I

B

HCM [33]

 CMR imaging is indicated in patients with known HCM when additional information that may have an impact on management or decision making regarding invasive management, such as magnitude and distribution of hypertrophy or anatomy of the mitral valve apparatus or papillary muscles, is not adequately defined with echocardiography.

I

B

HCM [33]

 CMR imaging is reasonable in patients with HCM to define apical hypertrophy and/or aneurysm if echocardiography is inconclusive.

IIa

B

HCM [33]

 In selected patients with known HCM, when SCD risk stratification is inconclusive after documentation of the conventional risk factors, CMR imaging with assessment of late gadolinium enhancement (LGE) may be considered in resolving clinical decision making.

IIb

C

HCM [33]

 The usefulness of the following potential SCD risk modifiers is unclear but might be considered in selected patients with HCM for whom risk remains borderline after documentation of conventional risk factors: CMR imaging with LGE.

IIb

C

HCM [33]

Athlete’s heart

 Extended monitoring (including MRI) can be beneficial for athletes with unexplained exertional syncope after an initial cardiovascular evaluation.

IIa

C-LD

Syncope [24]

Storage disease

 CMR imaging may be considered in patients with LV hypertrophy and the suspicion of alternative diagnoses to HCM, including cardiac amyloidosis, Fabry disease, and genetic phenocopies such as LAMP2 cardiomyopathy.

IIb

C

HCM [33]

Vascular disease

 Aortic magnetic resonance angiography or CT angiography is indicated in patients with a bicuspid aortic valve when morphology of the aortic sinuses, sinotubular junction, or ascending aorta cannot be assessed accurately or fully by echocardiography. (Level of Evidence: C)

I

C

Valve disease [7, 23]

 Serial evaluation of the size and morphology of the aortic sinuses and ascending aorta by echocardiography, CMR, or CT angiography is recommended in patients with a bicuspid aortic valve and an aortic diameter greater than 4.0 cm, with the examination interval determined by the degree and rate of progression of aortic dilation and by family history. In patients with an aortic diameter greater than 4.5 cm, this evaluation should be performed annually.

I

C

Valve disease [7, 23]

 Duplex ultrasound, computed tomography angiography (CTA), or magnetic resonance angiography (MRA) of the lower extremities is useful to diagnose anatomic location and severity of stenosis for patients with symptomatic peripheral artery disease in whom revascularization is considered

I

B-NR

Peripheral Artery Disease [4]

 Invasive and noninvasive angiography (ie, CTA, MRA) should not be performed for the anatomic assessment of patients with asymptomatic peripheral artery disease.

III

B-R

Peripheral Artery Disease [4]

 In patients with acute, focal ischemic neurological symptoms corresponding to the territory supplied by the left or right internal carotid artery, magnetic resonance angiography (MRA) or computed tomography angiography (CTA) is indicated to detect carotid stenosis when sonography either cannot be obtained or yields equivocal or otherwise nondiagnostic results.

I

C

Carotid and vertebral artery [20]

 When an extracranial source of ischemia is not identified in patients with transient retinal or hemispheric neurological symptoms of suspected ischemic origin, CTA, MRA, or selective cerebral angiography can be useful to search for intracranial vascular disease.

IIa

C

Carotid and vertebral artery [20]

 When the results of initial noninvasive imaging are inconclusive, additional examination by use of another imaging method is reasonable. In candidates for revascularization, MRA or CTA can be useful when results of carotid duplex ultrasonography are equivocal or indeterminate.

IIa

C

Carotid and vertebral artery [20]

 When intervention for significant carotid stenosis detected by carotid duplex ultrasonography is planned, MRA, CTA, or catheter-based contrast angiography can be useful to evaluate the severity of stenosis and to identify intrathoracic or intracranial vascular lesions that are not adequately assessed by duplex ultrasonography.

IIa

C

Carotid and vertebral artery [20]

 MRA without contrast is reasonable to assess the extent of disease in patients with symptomatic carotid atherosclerosis and renal insufficiency or extensive vascular calcification.

IIa

C

Carotid and vertebral artery [20]

 When complete carotid arterial occlusion is suggested by duplex ultrasonography, MRA, or CTA in patients with retinal or hemispheric neurological symptoms of suspected ischemic origin, catheter-based contrast angiography may be considered to determine whether the arterial lumen is sufficiently patent to permit carotid revascularization.

IIb

C

Carotid and vertebral artery [20]

 Noninvasive imaging by CTA or MRA for detection of vertebral artery disease should be part of the initial evaluation of patients with neurological symptoms referable to the posterior circulation and those with subclavian steal syndrome.

I

C

Carotid and vertebral artery [20]

 In patients whose symptoms suggest posterior cerebral or cerebellar ischemia, MRA or CTA is recommended rather than ultrasound imaging for evaluation of the vertebral arteries.

I

C

Carotid and vertebral artery [20]

 Contrast-enhanced CTA, MRA, and catheter-based contrast angiography are useful for diagnosis of cervical artery dissection.

I

C

Carotid and vertebral artery [20]

 Urgent and definitive imaging of the aorta using transesophageal echocardiogram, computed tomographic imaging, or magnetic resonance imaging is recommended to identify or exclude thoracic aortic dissection in patients at high risk for the disease by initial screening.

I

B

Thoracic aorta [21]

 The initial evaluation of Takayasu arteritis or giant cell arteritis should include thoracic aorta and branch vessel computed tomographic imaging or magnetic resonance imaging to inves- tigate the possibility of aneurysm or occlusive disease in these vessels.

I

C

Thoracic aorta [21]

 For patients with isolated aortic arch aneurysms less than 4.0 cm in diameter, it is reasonable to reimage using computed tomographic imaging or magnetic resonance imaging, at 12- month intervals, to detect enlargement of the aneurysm.

IIa

C

Thoracic aorta [21]

 For patients with isolated aortic arch aneurysms 4.0 cm or greater in diameter, it is reasonable to reimage using computed tomographic imaging or magnetic resonance imaging, at 6-month intervals, to detect enlargement of the aneurysm.

IIa

C

Thoracic aorta [21]

 For imaging of pregnant women with aortic arch, descending, or abdominal aortic dilatation, magnetic resonance imaging (without gadolinium) is recommended over computed tomographic imaging to avoid exposing both the mother and fetus to ionizing radiation. Transesophageal echocardiogram is an option for imaging of the thoracic aorta.

I

C

Thoracic aorta [21]

 Computed tomographic imaging or magnetic resonance imaging of the thoracic aorta is reasonable after a Type A or B aortic dissection or after prophylactic repair of the aortic root/ ascending aorta.

IIa

C

Thoracic aorta [21]

 Computed tomographic imaging or magnetic resonance imaging of the aorta is reasonable at 1, 3, 6, and 12 months postdissection and, if stable, annually thereafter so that any threatening enlargement can be detected in a timely fashion.

IIa

C

Thoracic aorta [21]

 If a thoracic aortic aneurysm is only moderate in size and remains relatively stable over time, magnetic resonance imaging instead of computed tomographic imaging is reasonable to minimize the patient’s radiation exposure.

IIa

C

Thoracic aorta [21]

 MRI for detection of vascular plaque is not recommended for cardiovascular risk assessment in asymptomatic adults.

III

C

Risk assessment [18]

Valvular heart disease

 CMR is indicated in patients with moderate or severe AR (stages B, C, and D) and suboptimal echocardiographic images for the assessment of LV systolic function, systolic and diastolic volumes, and measurement of AR severity.

I

B

Valve disease [7, 23]

 CMR is indicated in patients with chronic primary MR to assess LV and RV volumes, function, or MR severity and when these issues are not satisfactorily addressed by TTE.

I

B

Valve disease [7, 23]

 CMR or real-time 3D echocardiography may be considered for assessment of right ventricular systolic function and systolic and diastolic volumes in patients with severe tricuspid regurgitation (stages C and D) and suboptimal 2D echocardiograms.

IIb

C

Valve disease [7, 23]

Congenital heart disease

 Diagnostic and interventional procedures, including imaging (ie, echocardiography, MRI, or CT, advanced cardiac catheterization, and electrophysiology procedures for adults with complex and moderate CHD should be performed in a regional ACHD center with appropriate experience in CHD and in a laboratory with appropriate personnel and equipment. Personnel performing such procedures should work as part of a team with expertise in the surgical and transcatheter management of patients with CHD.

I

C

Congenital heart disease [19]

 (In bicuspid aortic valve disease) MRI/CT can be beneficial to add important information about the anatomy of the thoracic aorta.

IIa

C

Congenital heart disease [19]

 (In bicuspid aortic valve disease) MRI may be beneficial in quantifying aortic regurgitation when other data are ambiguous or borderline.

IIb

C

Congenital heart disease [19]

 (In supravalvular aortic stenosis) TTE and/or TEE with Doppler and either MRI or CT should be performed to assess the anatomy of the LVOT, the ascending aorta, coronary artery anatomy and flow, and main and branch pulmonary artery anatomy and flow.

I

C

Congenital heart disease [19]

 Every patient with coarctation (repaired or not) should have at least 1 cardiovascular MRI or CT scan for complete evaluation of the thoracic aorta and intracranial vessels.

I

B

Congenital heart disease [19]

 Evaluation of the coarctation repair site by MRI/CT should be performed at intervals of 5 years or less, depending on the specific anatomic findings before and after repair.

I

C

Congenital heart disease [19]

 Patients with suspected supravalvular, branch, or peripheral pulmonary stenosis should have baseline imaging with echocardiography-Doppler plus 1 of the following: MRI angiography, CT angiography, or contrast angiography.

I

C

Congenital heart disease [19]

 (In congenital coronary anomalies of ectopic arterial origin) CT or MRA is useful as the initial screening method in centers with expertise in such imaging.

I

B

Congenital heart disease [19]

 (In suspicion of a coronary arteriovenous fistula), if a continuous murmur is present, its origin should be defined either by echocardiography, MRI, CT angiography, or cardiac catheterization.

I

C

Congenital heart disease [19]

 The evaluation of all ACHD patients with suspected pulmonary arterial hypertension should include noninvasive assessment of cardiovascular anatomy and potential shunting, as detailed below: Diagnostic cardiovascular imaging via TTE, TEE, MRI, or CT as appropriate.

I

C

Congenital heart disease [19]

 Patients with tetralogy of Fallot should have echocardiographic examinations and/or MRIs performed by staff with expertise in ACHD.

I

C

Congenital heart disease [19]

 Additional imaging with TEE, CT, or MRI, as appropriate, should be performed in a regional ACHD center to evaluate the great arteries and veins, as well as ventricular function, in patients with prior atrial baffle repair of d-TGA.

I

B

Congenital heart disease [19]

 Periodic MRI or CT can be considered appropriate to evaluate the anatomy and hemodynamics in more detail in patients with prior arterial switch operation.

IIa

C

Congenital heart disease [19]

 (In congenitally corrected transposition of the great arteries), echocardiography-Doppler study and/or MRI should be performed yearly or at least every other year by staff trained in imaging complex CHD.

I

C

Congenital heart disease [19]

 The following diagnostic evaluations are recommended for patients with congenitally corrected transposition of the great arteries: ECG, chest x-ray, echocardiography-Doppler study, MRI, exercise testing.

I

C

Congenital heart disease [19]

 (In patients with prior repair of congenitally corrected transposition of the great arteries), echocardiography-Doppler study and/or MRI should be performed yearly or at least every other year by staff trained in imaging complex CHD.

I

C

Congenital heart disease [19]

 All patients with prior Fontan type of repair should have periodic echocardiographic and/or magnetic resonance examinations performed by staff with expertise in ACHD.

I

C

Congenital heart disease [19]

Syncope

 Computed tomography (CT) or magnetic resonance imaging (MRI) may be useful in selected patients presenting with syncope of suspected cardiac etiology.

IIb

B-NR

Syncope [24]