Chronic stable angina cardiac magnetic resonance imaging

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Smita Kohli, M.D.; Lakshmi Gopalakrishnan, M.B.B.S.; Aysha Anwar, M.B.B.S[3]


Cardiac magnetic resonance imaging (CMRI) is a non-invasive test that is useful in the evaluation of overall coronary anatomy and function. CMRI also helps in the identification of inflammation,[1] neovascularization[2] and fibrous cap,[3] It, therefore, holds the potential for plaque characterization.

Cardiac Magnetic Resonance Imaging

Indications for CMR based on Consensus Panel report[4]

Class I

1. Assessment of global ventricular (left and right) function and mass

2. Detection of coronary artery disease

a. Coronary MRA (anomalies)

3. Acute and chronic myocardial infarction

a. Detection and assessment
b. Myocardial viability

Class II

1. Detection of coronary artery disease

a. Regional left ventricular function at rest and during dobutamine stress
b. Assessment of myocardial perfusion
c. Coronary MRA of bypass graft patency

2. Acute and chronic myocardial infarction

a. Ventricular thrombus

Class III

1. Detection of coronary artery disease

a. Coronary MRA (CAD)

2. Acute and chronic myocardial infarction

a. Ventricular septal defect
b. Mitral regurgitation (acute MI)

Class Inv

1. Detection of coronary artery disease

a. MR flow measurements in the coronary arteries
b. Arterial wall imaging

2. Acute and chronic myocardial infarction

a. Acute coronary syndromes


  • Class I: provides clinically relevant information and is usually appropriate; may be used as first line imaging technique; usually supported by substantial literature.
  • Class II: provides clinically relevant information and is frequently useful; other techniques may provide similar information; supported by limited literature.
  • Class III: provides clinically relevant information but is infrequently used because information from other imaging techniques is usually adequate.
  • Class Inv: potentially useful, but still investigational.

Detection of CAD using CMRI

  • Early detection of atherosclerosis and endothelial dysfunction using CMRI is possible with arterial wall imaging and assessing the reactivity of brachial artery.
  • CMRI can be used to image arteries outside the heart [5] which are affected long before the clinical manifestations of atherosclerosis.[6]
  • Direct endothelial function can be measured non-invasively using stimuli that causes flow mediated arterial vasodilatation.[7] CMRI measures flow changes in response to stimuli in addition to measuring brachial dilation.[8]
  • Alternative approaches include:
  • Visualization of the effects of induced ischemia (wall motion, perfusion)
  • Stress wall motion abnormalities: In patients with CAD, dobutamine stress CMR is helpful to identify ischemia-induced wall motion abnormalities[9] and is considered effective is patients who are unsuitable for dobutamine echocardiography.[10]
  • Myocardial perfusion: In patients with CAD, CMR showed improvement in myocardial perfusion after coronary angioplasty[11] and in patients with cadiac syndrome X impaired sub-endocardial perfusion was observed.[12]
  • Direct visualization of coronary arteries (coronary angiography and flow)
  • Coronary angiography and coronary flow evaluation: Coronary flow reserve is useful in the identification of LAD stenosis[13] and in-stent restenosis.[14] CMR imaging is also very accurate in the prediction of graft patency.[15]

ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)[16]

Stress Testing and Advanced Imaging for Initial Diagnosis in Patients With Suspected SIHD Who Require Noninvasive Testing (DO NOT EDIT)[16]

Patients able to exercise

Class IIa
"1. Pharmacological stress with CMR can be useful for patients with an intermediate to high pretest probability of obstructive IHD who have an uninterpretable ECG and at least moderate physical functioning or no disabling comorbidity.(Level of Evidence: B)"
Class III
"1. Pharmacological stress with nuclear MPI, echocardiography, or CMR is not recommended for patients who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity.(Level of Evidence: C)"

Pateints unable to exercise

Class IIa
"1. Pharmacological stress CMR is reasonable for patients with an intermediate to high pretest probability of IHD who are incapable of at least moderate physical functioning or have disabling comorbidity.(Level of Evidence: B)"


  1. Ruehm SG, Corot C, Vogt P, Kolb S, Debatin JF (2001) Magnetic resonance imaging of atherosclerotic plaque with ultrasmall superparamagnetic particles of iron oxide in hyperlipidemic rabbits. Circulation 103 (3):415-22. PMID: 11157694
  2. Kerwin W, Hooker A, Spilker M, Vicini P, Ferguson M, Hatsukami T et al. (2003) Quantitative magnetic resonance imaging analysis of neovasculature volume in carotid atherosclerotic plaque. Circulation 107 (6):851-6. PMID: 12591755
  3. Wasserman BA, Smith WI, Trout HH, Cannon RO, Balaban RS, Arai AE (2002) Carotid artery atherosclerosis: in vivo morphologic characterization with gadolinium-enhanced double-oblique MR imaging initial results. Radiology 223 (2):566-73. PMID: 11997569
  4. Pennell DJ, Sechtem UP, Higgins CB, Manning WJ, Pohost GM, Rademakers FE et al. (2004) Clinical indications for cardiovascular magnetic resonance (CMR): Consensus Panel report. Eur Heart J 25 (21):1940-65. DOI:10.1016/j.ehj.2004.06.040 PMID: 15522474
  5. Cai JM, Hatsukami TS, Ferguson MS, Small R, Polissar NL, Yuan C (2002) Classification of human carotid atherosclerotic lesions with in vivo multicontrast magnetic resonance imaging. Circulation 106 (11):1368-73. PMID: 12221054
  6. Glagov S, Weisenberg E, Zarins CK, Stankunavicius R, Kolettis GJ (1987) Compensatory enlargement of human atherosclerotic coronary arteries. N Engl J Med 316 (22):1371-5. DOI:10.1056/NEJM198705283162204 PMID: 3574413
  7. Celermajer DS, Sorensen KE, Gooch VM, Spiegelhalter DJ, Miller OI, Sullivan ID et al. (1992) Non-invasive detection of endothelial dysfunction in children and adults at risk of atherosclerosis. Lancet 340 (8828):1111-5. PMID: 1359209
  8. Silber HA, Bluemke DA, Ouyang P, Du YP, Post WS, Lima JA (2001) The relationship between vascular wall shear stress and flow-mediated dilation: endothelial function assessed by phase-contrast magnetic resonance angiography. J Am Coll Cardiol 38 (7):1859-65. PMID: 11738285
  9. Nagel E, Lorenz C, Baer F, Hundley WG, Wilke N, Neubauer S et al. (2001) Stress cardiovascular magnetic resonance: consensus panel report. J Cardiovasc Magn Reson 3 (3):267-81. PMID: 11816623
  10. Hundley WG, Hamilton CA, Thomas MS, Herrington DM, Salido TB, Kitzman DW et al. (1999) Utility of fast cine magnetic resonance imaging and display for the detection of myocardial ischemia in patients not well suited for second harmonic stress echocardiography. Circulation 100 (16):1697-702. PMID: 10525488
  11. Al-Saadi N, Nagel E, Gross M, Schnackenburg B, Paetsch I, Klein C et al. (2000) Improvement of myocardial perfusion reserve early after coronary intervention: assessment with cardiac magnetic resonance imaging. J Am Coll Cardiol 36 (5):1557-64. PMID: 11079658
  12. Panting JR, Gatehouse PD, Yang GZ, Grothues F, Firmin DN, Collins P et al. (2002) Abnormal subendocardial perfusion in cardiac syndrome X detected by cardiovascular magnetic resonance imaging. N Engl J Med 346 (25):1948-53. DOI:10.1056/NEJMoa012369 PMID: 12075055
  13. Hundley WG, Hamilton CA, Clarke GD, Hillis LD, Herrington DM, Lange RA et al. (1999) Visualization and functional assessment of proximal and middle left anterior descending coronary stenoses in humans with magnetic resonance imaging. Circulation 99 (25):3248-54. PMID: 10385498
  14. Nagel E, Thouet T, Klein C, Schalla S, Bornstedt A, Schnackenburg B et al. (2003) Noninvasive determination of coronary blood flow velocity with cardiovascular magnetic resonance in patients after stent deployment. Circulation 107 (13):1738-43. DOI:10.1161/01.CIR.0000060542.79482.81 PMID: 12665488
  15. Langerak SE, Kunz P, Vliegen HW, Jukema JW, Zwinderman AH, Steendijk P et al. (2002) MR flow mapping in coronary artery bypass grafts: a validation study with Doppler flow measurements. Radiology 222 (1):127-35. PMID: 11756716
  16. 16.0 16.1 Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP; et al. (2012). "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 126 (25): 3097–137. doi:10.1161/CIR.0b013e3182776f83. PMID 23166210.

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