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Stress CMR Perfusion-LGE Interpretation — EECC MCQ

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ModerateCardiac ImagingStress CMR Perfusion-LGE InterpretationEECC

A 65-year-old man undergoes stress perfusion CMR showing a perfusion defect in the LAD territory without LGE (no scar). What does this combination indicate?

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Correct answer: E — Reversible ischaemia without infarction — a perfusion defect (reduced first-pass gadolinium enhancement during stress) in the absence of LGE indicates viable, ischaemic myocardium that would benefit from revascularisation

Stress perfusion CMR interpretation per the 2024 ESC CCS Guidelines: (1) perfusion defect on stress images WITHOUT LGE = reversible ischaemia (viable myocardium with flow-limiting stenosis — the substrate that benefits most from revascularisation); (2) perfusion defect WITH matched LGE = infarction/scar within the ischaemic territory (extent of LGE transmurality determines viability — ≤50% transmural = viable, may benefit from revascularisation); (3) LGE WITHOUT perfusion defect = scar without active ischaemia (prior MI, fully revascularised or collateralised territory); (4) normal perfusion, no LGE = no ischaemia or infarction. Stress CMR has sensitivity ~90% and specificity ~80% for significant CAD, comparable to SPECT/PET. The CE-MARC and MR-INFORM trials validated CMR-guided management as non-inferior to FFR-guided strategies.

Reference: ESC (2024): CCS; CE-MARC/MR-INFORM Trials