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Atrial fibrillation (AF) in hypertrophic cardiomyopathy (HC) is associated with significant symptomatic deterioration, heart failure, and thromboembolic disease. There is a need for better mechanistic insight and improved identification of at risk patients. We used cardiovascular magnetic resonance (CMR) to assess predictors of AF in HC, in particular the role of myocardial fibrosis. Consecutive patients with HC referred for CMR 2003 to 2013 were prospectively enrolled. CMR parameters including left ventricular volumes, presence and percentage of late gadolinium enhancement in the left ventricle (%LGE) and left atrial volume index (LAVi) were measured. Overall, 377 patients were recruited (age 62 ± 14 years, 73% men). Sixty-two patients (16%) developed new-onset AF during a median follow up of 4.5 (interquartile range 2.9 to 6.0) years. Multivariable analysis revealed %LGE (hazard ratio [HR] 1.3 per 10% (confidence interval: 1.0 to 1.5; p = 0.02), LAVi (HR 1.4 per 10 mL/m 2[1.2 to 1.5; p < 0.001]), age at HC diagnosis, nonsustained ventricular tachycardia and diabetes to be independent predictors of AF. We constructed a simple risk prediction score for future AF based on the multivariable model with a Harrell's C-statistic of 0.73. In conclusion, the extent of ventricular fibrosis and LA volume independently predicted AF in patients with HC. This finding suggests a mechanistic relation between fibrosis and future AF in HC. CMR with quantification of fibrosis has incremental value over LV and LA measurements in risk stratification for AF. A risk prediction score may be used to identify patients at high risk of future AF who may benefit from more intensive rhythm monitoring and a lower threshold for oral anticoagulation.

Aims This study aimed to analyse community management of patients during the symptomatic period prior to admission with acute decompensated heart failure (ADHF). Methods and results We conducted a prospective, two‐centre, two‐country observational study evaluating care pathways and patient experience in patients admitted to hospital with ADHF. Quantitative and qualitative data were gathered from patients, carers, and general practitioners (GPs). From the Irish centre, 114 patients enrolled, and from the English centre, 50 patients. Symptom duration longer than 72 h prior to hospitalization was noted among 70.4% (76) Irish and 80% (40) English patients, with no significant difference between those with a new diagnosis of HF [de novo HF (dnHF)] and those with known HF [established HF (eHF)] in either cohort. For the majority, dyspnoea was the dominant symptom; however, 63.3% (31) of these Irish patients and 47.2% (17) of these English patients did not recognize this as an HF symptom, with no significant difference between dnHF and eHF patients. Of the 46.5% (53) of Irish and 38% (19) of English patients reviewed exclusively by GPs before hospitalization, numbers prescribed diuretics were low (11.3%, six; and 15.8%, three, respectively); eHF patients were no more likely to receive diuretics than dnHF patients. Barriers to care highlighted by GPs included inadequate access to basic diagnostics, specialist support and up‐to‐date patient information, and lack of GP comfort in managing HF. Conclusion The aforementioned findings, consistent across both health care jurisdictions, show a clear potential to intervene earlier and more effectively in ADHF or to prevent the need for hospitalization.

Background Delayed hospital presentation with STEMI during the SARS-CoV-2 pandemic can lead to increased incidence of typically rare mechanical sequelae Intramyocardial dissecting hematoma (IDH) is one such complication of myocardial infarction Case A 51 year-old male patient with a background of hypertension presented with a 7 hour history of typical chest pain His initial ECG showed anterolateral ST segment elevation with reciprocal ST depression in the inferior leads, consistent with STEMI Urgent angiography revealed a 100% acute occlusion in the mid-LAD TIMI 3 flow was restored using a Xience 3 00 x 18mm stent, with resolution of pain and interval ECG improvement Laboratory investigations revealed new significant anaemia Decision-making Post-procedural transthoracic echocardiography revealed severely impaired systolic function and moderate concentric biventricular hypertrophy, and raised the suspicion of a mechanical complication (see image) This was further supported by his delayed presentation and extensive infarct area His anaemia was suggestive of active haemorrhage Endoscopic investigation failed to show a gastrointestinal source Cardiac MRI (CMR) confirmed the presence of IDH Conclusion This case highlights the need for a heightened index of suspicion for typically rare mechanical complications post-STEMI due to delayed hospital presentation during the current pandemic, as well as the growing utility of multimodality imaging such as CMR [Formula presented]

This study explored whether cardiac magnetic resonance (CMR) could help select patients who could benefit from revascularization by identifying inducible myocardial ischemia and viability in the perfusion territory of the artery with chronic total occlusion (CTO).The benefit of revascularization using percutaneous coronary intervention (PCI) in CTO is controversial. CMR offers incomparable left ventricular (LV) systolic function assessment in addition to potent ischemic burden quantification and reliable myocardial viability analysis. Whether CMR guided CTO revascularization would be helpful to such patients has not yet been explored fully.A prospective study of 50 consecutive CTO patients was conducted. Of 50 patients undergoing baseline stress CMR, 32 (64%) were selected for recanalization based on the presence of significant inducible perfusion deficit and myocardial viability within the CTO arterial territory. Patients were rescanned 3 months after successful CTO recanalization.At baseline, myocardial perfusion reserve (MPR) in the CTO territory was significantly reduced compared with the remote region (1.8 ± 0.72 vs. 2.2 ± 0.7; p = 0.01). MPR in the CTO region improved significantly after PCI (to 2.3 ± 0.9; p = 0.02 vs. baseline) with complete or near-complete resolution of CTO related perfusion defect in 90% of patients. Remote territory MPR was unchanged after PCI (2.5 ± 1.2; p = NS vs. baseline). The LV ejection fraction increased from 63 ± 13% to 67 ± 12% (p 0.0001) and end-systolic volume decreased from 65 ± 38 to 56 ± 38 ml (p 0.001) 3 months after CTO PCI. Importantly, despite minimal post-procedural infarction due to distal embolization and side branch occlusion in 8 of 32 patients (25%), the total Seattle Angina Questionnaire score improved from a median of 54 (range 45 to 74) at baseline to 89 (range 77 to 98) after CTO recanalization (p 0.0001).In this small group of patients showing CMR evidence of significant myocardial inducible perfusion defect and viability, CTO recanalization reduces ischemic burden, favors reverse remodeling, and ameliorates quality of life.

Introduction The prognosis and treatment of the two main types of cardiac amyloidosis, immunoglobulin light chain (AL) and transthyretin (ATTR) amyloidosis, are substantially influenced by cardiac involvement. Focal myocardial fibrosis is best detected and quantified by cardiovascular magnetic resonance (CMR) and late gadolinium enhancement (LGE) technique. Diffuse subendocardial and transmural LGE is a marker of late cardiac amyloidosis. This report describes the use of CMR to detect early cardiac manifestations in amyloidosis and to evaluate its progression over a five-year period. Methods Mr GS is a 77 year old gentleman who was diagnosed with cardiac amyloidosis in 2012. He attends follow-up annual review appointments at the National Amyloid Centre in University College London. He has undergone annual CMR at Blackrock clinic Dublin from 2014 until 2017. GS underwent LGE imaging for myocardial scar using a segmented Inversion recovery-technique 10 to 15 min after injection of 0.1 mmol/kg of gadolinium. Myocardial enhancement was assessed visually and interpreted by two cardiac CMR-trained physicians. Results A short axis of LGE imaging from GS is shown in figure 1 which demonstrates significant, confluent myocardial fibrosis throughout the myocarium. Figure 2 highlights the evolution of amyloidosis from 2014–2017 which shows a gradual increase in LGE uptake throughout the vertical long axis (VLA), horizontal long axis (HLA) and short axis (SA) images. There has been a clear deterioration in appearances with the most striking images of LGE seen in November 2017. The findings correspond with functional deterioration in heart failure symptoms and increasing B-type natriuretic peptide (BNP), peaking at 7,500 pg/ml. Conclusion LGE is a sensitive parameter for the early diagnosis of cardiomyopathy in amyloidosis and can be used to show progression of disease.

Introduction Interstitial myocardial fibrosis is best detected and quantified by cardiovascular magnetic resonance (CMR). It may be accurately detected by late gadolinium enhancement (LGE) and T1 relaxation mapping. Duchenne muscular dystrophy (DMD) is an X-linked recessive disease that occurs in males leading to cardiomyopathy and death in early adulthood. This report describes the use of CMR to detect early cardiac manifestations in DMD and to evaluate its progression over a five-year period in two young patients. Methods Yearly CMR was performed on two brothers (patient one aged 16 and patient two aged 14) from 2013 until 2017. All patients underwent LGE imaging for myocardial scar using a segmented Inversion recovery-technique 10 to 15 min after injection of 0.1 mmol/kg of gadolinium. Myocardial enhancement was assessed visually and interpreted by two cardiac CMR-trained physicians. T1 mapping techniques were used on the latest scan in November 2017. Results A short axis stack of LGE imaging from patient one is shown in figure 1 which demonstrates significant, confluent myocardial fibrosis in the anterolateral, lateral and inferolateral walls from base through to the distal LV segments. The total gadolinium volume was 15 g (24% of the total myocardium), with a T1 mapping value of 1105 ms (normal local mean 957 ms), figure 2. Figure 3 highlights the evolution of DMD in these two patients from 2013–2017 which shows a gradual increase in LGE throughout the horizontal long axis (HLA) and short axis (SA) images of each patient. There has been a clear deterioration in appearances with the most striking images of LGE seen in November 2017. Conclusion LGE is a sensitive parameter for the early diagnosis of cardiomyopathy in DMD and can be used to show progression of disease.

Introduction Heart failure develops in 3%–5% of patients with hypertrophic cardiomyopathy (HCM) and is associated with a ten-fold increase in mortality. Myocardial perfusion abnormalities using positron emission tomography (PET) predict patients at increased risk of heart failure and death, however the mechanism of these perfusion defects has not been demonstrated, nor has the added prognostic value of perfusion imaging over late gadolinium imaging been established. Methods We measured simultaneous pressure and flow in the proximal left anterior descending artery in 33 HCM and 20 control patients at rest and during hyperemia, allowing calculation of wave intensity (WIA). Patients underwent quantitative first-pass perfusion cardiovascular magnetic resonance (CMR). We prospectively recruited a further 328 HCM patients for CMR, including adenosine first pass perfusion, LV and LA volumes and late gadolinium enhancement (LGE). We followed patients for development of heart failure, with a composite endpoint of heart failure death, cardiac transplantation and unplanned heart failure hospitalisation. Results Patients with HCM had a lower coronary flow reserve than controls (1.9±0.8 versus 2.7±0.9, p=0.001). Coronary hemodynamics in HCM were characterised by a very large backward compression wave during systole (38%±11% versus 21±6%, p The proportion of waves acting to accelerate coronary flow increased with hyperemia and the magnitude of change was proportional to the myocardial perfusion reserve. (r=0.62, p During a median follow up of 3.2 years, 32 patients met the heart failure endpoint. Baseline left atrial volume indexed to body surface area, LAVi, (HR 1.38 (1.2–1.6), p Discussion Coronary flow in patients with HCM is deranged. Distally, compressive deformation of intra-myocardial blood vessels during systole result in an abnormally large backward compression wave, while proximally, severe LVOT obstruction is associated with an additional deceleration wave. Perfusion abnormalities in HCM are not simply a consequence of supply/demand mismatch or remodelling of the intra-myocardial blood vessels but represent a dynamic interaction with myocardial mechanics which may be amenable to treatment. In our prognostic study, we identified that while replacement fibrosis was a likely mechanism of progression to heart failure, LAVi as a more global measure of ventricular dysfunction was the strongest prognostic marker in HCM. Although perfusion using PET predicted development of heart failure in HCM, perfusion imaging with CMR did not predict outcome. Perfusion defects in HCM are complex and multifactorial, however do not correlate directly with outcome in large, prospective studies and should not be included in risk stratification scores.

Aims Prevention of cardiovascular disease and heart failure (HF) in a cost-effective manner is a public health goal. This work aims to assess the cost-effectiveness of the St Vincent's Screening TO Prevent Heart Failure (STOP-HF) intervention. Methods and results This is a substudy of 1054 participants with cardiovascular risk factors [median age 65.8 years, interquartile range (IQR) 57.8:72.4, with 4.3 years, IQR 3.4:5.2, follow-up]. Annual natriuretic peptide-based screening was performed, with collaborative cardiovascular care between specialist physicians and general practitioners provided to patients with BNP levels >50 pg/mL. Analysis of cost per case prevented and cost-effectiveness per quality-adjusted life year (QALY) gained was performed. The primary clinical endpoint of LV dysfunction (LVD) with or without HF was reduced in intervention patients [odds ratio (OR) 0.60; 95% confidence interval (CI) 0.38–0.94; P = 0.026]. There were 157 deaths and/or emergency hospitalizations for major adverse cardiac events (MACE) in the control group vs. 102 in the intervention group (OR 0.68; 95% CI 0.49–0.93; P = 0.01). The cost per case of LVD/HF prevented was €9683 (sensitivity range –€843 to €20 210), whereas the cost per MACE prevented was €3471 (sensitivity range –€302 to €7245). Cardiovascular hospitalization savings offset increased outpatient and primary care costs. The cost per QALY gain was €1104 and the intervention has an 88% probability of being cost-effective at a willingness to pay threshold of €30 000. Conclusion Among patients with cardiovascular risk factors, natriuretic peptide-based screening and collaborative care reduced LVD, HF, and MACE, and has a high probability of being cost-effective. Trial registration NCT00921960

Background— Pathological T-wave inversion (PTWI) is rarely observed on the ECG of healthy athletes, whereas it is common in patients with certain cardiac diseases. All ECG interpretation guidelines for use within athletes state that PTWI (except in leads aVR, III and V1 and in V1–V4 when preceded by domed ST segment in asymptomatic Afro-Caribbean athletes only) cannot be considered a physiological adaptation. The aims of the present study were to prospectively determine the prevalence of cardiac pathology in athletes presenting with PTWI, and to examine the efficacy of cardiac magnetic resonance in the work-up battery of further examinations. Methods and Results— Athletes presenting with PTWI (n=155) were investigated with clinical examination, ECG, echocardiography, exercise testing, 24h Holter ECG, and cardiac magnetic resonance. Cardiac disease was established in 44.5% of athletes, with hypertrophic cardiomyopathy (81%) the most common pathology. Echocardiography was abnormal in 53.6% of positive cases, and cardiac magnetic resonance identified a further 24 athletes with disease. Five athletes (7.2%) considered normal on initial presentation subsequently expressed pathology during follow-up. Familial history of sudden cardiac death and ST-segment depression associated with PTWI were predictive of cardiac disease. Conclusions— PTWI should be considered pathological in all cases until proven otherwise, because it was associated with cardiac pathology in 45% of athletes. Despite echocardiography identifying pathology in half of these cases, cardiac magnetic resonance must be considered routine in athletes presenting with PTWI with normal echocardiography. Although exclusion from competitive sport is not warranted in the presence of normal secondary examinations, annual follow-up is essential to ascertain possible disease expression.

We assessed adherence to European Society of Cardiology heart rate guidelines (i.e. heart rates less than 70 bpm) in patients with chronic stable heart failure. We also investigated the percent of patients on target doses of rate controlling drugs.Multicenter study involving 549 patients from 12 heart failure centers in the Republic of Ireland. Patients in sinus rhythm with stabilized heart failure treatment and without recent cardiac events were included. Resting heart rates, demographics, co-morbidities and heart failure therapies were recorded.Heart rates ≥ 70 bpm were noted in 176 (32.1%) patients with 117 (21.3%) having rates75 bpm. Non-achievement of target heart rates were unrelated to age, gender or most cardiovascular risk factors. However, 42% of patients with diabetes (p0.01), 56% of those with COPD (p0.0001) and 46% of those with NYHA Class 3 (p0.05) did not achieve target heart rates. Fifty eight (11%) subjects were not on beta-blockers and of these forty subjects (69%) (p0001) did not achieve target heart rates. Of those on beta-blockers only 25% were at target dose. However, beta-blocker dosage was unrelated to achieving target heart rates. Ivabradine was used in 11% of patients with 10% at target dosage.This study highlights that a third of "stabilized" chronic heart failure patients have not reached recommended target heart rates. Respiratory problems, diabetes and marked dyspnea were associated with poorer rate control. Guideline unawareness, inadequate beta-blocker titration and under use of ivabradine may prevent patients gaining the proven benefits of heart rate control.

Background Two-dimensional Doppler-echocardiography (2 DE) remains the primary modality in assessing left ventricular diastolic dysfunction (LVDD) due to its widespread availability. In asymptomatic LVDD (ALVDD), the putative precursor of diastolic heart failure, 2 DE imaging of cardiac volume and mass has been reported to be prognostically significant. However, the consistency of such measures is not fully known with limited data on sequential imaging. We aimed to compare reproducibility of cardiac volumes and mass by sequential 2 DE against cardiac magnetic resonance imaging (CMR), the gold standard in evaluating volumes and mass, in patients with ALVDD. Methods We sub-analysed imaging data from a prospective randomized clinical study (EudraCT 2010-021664-16) evaluating the impact of chronic doxycycline therapy on cardiac remodeling in patients with ALVDD, using 2 DE and CMR. Both modalities were performed by independent blinded observers at baseline, 6 months and 12 months. Cardiac volumes and mass were indexed to body surface area at each timepoint for all patients. Pearson’s correlation was performed between measurements of both modalities at (baseline, 6 months, 12 months) respectively. Results were reported as mean ± SD. Results All patients (n=48) had mean age 69.8 ± 8.5 years and ejection fraction (EF) 67 ± 7% at baseline. Sequential correlations in EF (0.20, 0.15, 0.34), p = 0.17, 0.32, 0.02 respectively; and left ventricular end-diastolic volume index (LVEDVi) (0.37 , 0.17 , 0.07), p = 0.01, 0.27, 0.65 respectively, were compared between both modalities. Modest but significant correlations were observed between 2 DE and CMR for left atrial volume index (LAVi) (0.39, 0.50, 0.45), left ventricular mass index (LVMi)(0.46, 0.30 , 0.45) and left ventricular end-systolic volume index (LVESVi) ( 0.43, 0.58 , 0.48 ); all p Conclusion 2 DE-measured EF and LVEDVi demonstrated a predominantly poor correlation with CMR. However, 2 DE demonstrated modest correlation in LAVI, LVMI and LVESVi. The reproducibility of these sequential measurements against CMR supports their use as durable targets for measuring impact of therapies for ALVDD.

Aims Heart failure (HF) patients may be at risk of prescription of potentially inappropriate medicines (PIMs) yet no disease-specific list is available to assess PIM use in this population. A Consensus Potentially Inappropriate Medicines in Heart Failure (PIMHF) list was developed, assessed, and compared with an established, general tool in an ambulatory HF population. Methods and results The Consensus PIMHF list was compiled using modified Delphi methodology with a multidisciplinary team. The list consisted of 11 items. The medication profile of 350 patients was assessed. The association of a Consensus PIMHF item use over a median follow-up period of 1.8 (interquartile range 1.3–2.1) years with the primary endpoint of death, acute hospitalization, or unscheduled outpatient visit was examined. Fifty-one patients (14.6%) were prescribed ≥1 Consensus PIMHF item. In univariable analysis, patients prescribed ≥1 Consensus PIMHF item were 58% more likely to experience the primary endpoint than those with none [95% confidence interval (CI) 1.02–2.45]. When adjusted for age, sex, and HF severity, this difference remained [hazard ratio (HR) 1.88, 95% CI 1.16–3.06] and these associations were in contrast to the use of a more general tool (HR 1.24, 95% CI 0.83–1.84). However, when further adjusted to include co-morbidity score and polypharmacy, there was no association with outcome using either tool (HR 1.40, 95% CI 0.83–2.38; HR 1.05, 95% CI 0.69–1.60, respectively). Conclusion The Consensus PIMHF list provides the first HF-specific medicines review tool. These results provide some support for more disease-specific tools with limited lists of PIMs to rationalize medicines management in HF. However, more prospective work on the application of these tools in practice is needed.

We evaluated the extent to which left ventricular diastolic dysfunction (LVDD) contributes to the high false-positive rates observed when natriuretic peptides (NPs) are used to screen for left ventricular systolic dysfunction (LVSD), and the use of NPs in combination with electrocardiogram (ECG) to screen for pre-clinical ventricular dysfunction (PCVD).Eight hundred and fourteen patients over 40 years of age and with at least one cardiovascular risk factor were recruited. Screening strategies for LVSD included brain natriuretic peptide (BNP) alone at cut-offs of 20, 50, and 100 pg/mL, and BNP and abnormal ECG combined. Systolic and diastolic function was assessed by Doppler echocardiography. A left ventricular ejection fraction (LVEF) of50% was present in 33 (4.1%) of subjects, while 11 (1.4%) had LVEF40%. At a cut-off of 20, 50, and 100 pg/mL, sensitivity for BNP alone when screening for LVSD was 88, 70, and 45%, and specificity 46, 77, and 90%, respectively. Of those labelled 'false positive' in the 20, 50, and 100 pg/mL cut-off groups, 26, 46, and 65%, respectively, were found to have significant LVDD (left atrial volume index34 mL/m(2)). Optimal sensitivity (80%) and specificity (72%) for PCVD was obtained when BNP at a cut-off of 50 pg/mL or an abnormal ECG were defined as a positive screen so that only this group would be sent for Doppler echocardiography.A significant number of patients at risk for LVSD and labelled false positive with screening were found to have LVDD. Identifying this at-risk cohort may improve outcomes, but the clinical and economic benefit of this screening strategy requires formal assessment.

Aims Previous studies have demonstrated poor sensitivity of guideline weight monitoring in predicting clinical deterioration of heart failure (HF). This study aimed to evaluate patterns of remotely transmitted daily weights in a high-risk HF population and also to compare guideline weight monitoring and an individualized weight monitoring algorithm. Methods and results Consenting, consecutive, high-risk patients were provided with a mobile phone-based remote weight telemonitoring device. We aimed to evaluate population vs. individual weight variability, weight patterns pre- and post-events of clinical deterioration of HF, and to compare guideline weight thresholds with the HeartPhone algorithm in terms of sensitivity and specificity for such events. Of 87 patients recruited and followed for an average of 23.9 ± 12 weeks, 19 patients experienced 28 evaluable episodes of clinical deterioration of HF. Following a post-discharge decline, the population average weight remained stable for the follow-up period, yet the 7-day moving average of individual patients exceeded 2 kg in three-quarters of patients. Significant increases in weight were observed up to 4 days before HF events. The HeartPhone algorithm was significantly more sensitive (82%) in predicting HF events than guideline weight thresholds of 2 kg over 2–3 days (21%) and a ‘rule of thumb’ threshold of 1.36 kg over 1 day (46%). Conclusions An individualized approach to weight monitoring in HF with the HeartPhone algorithm improved prediction of HF deterioration. Further evaluation of HeartPhone with and without other biomarkers of HF deterioration is warranted.

Long-term high-intensity physical activity is associated with morphological changes, termed as the 'athlete's heart'. The differentiation of physiological cardiac adaptive changes in response to high-level exercise from pathological changes consistent with an inherited cardiomyopathy is imperative. Cardiovascular magnetic resonance (CMR) imaging allows definition of abnormal processes occurring at the tissue level, including, importantly, myocardial fibrosis. It is therefore vital in accurately making this differentiation. In this review, we will review the role of CMR imaging of fibrosis, and detail CMR characterisation of myocardial fibrosis in various cardiomyopathies, and the implications of fibrosis. Additionally, we will outline advances in imaging fibrosis, in particular T1 mapping. Finally we will address the role of CMR in pre-participation screening.

International audience; Preparticipation screening programmes for underlying cardiac pathologies are now commonplace for many international sporting organisations. However, providing medical clearance for an asymptomatic athlete without a family history of sudden cardiac death (SCD) is especially challenging when the athlete demonstrates particularly abnormal repolarisation patterns, highly suggestive of an inherited cardiomyopathy or channelopathy. Deep T-wave inversions of ≥ 2 contiguous anterior or lateral leads (but not aVR, and III) are of major concern for sports cardiologists who advise referring team physicians, as these ECG alterations are a recognised manifestation of hypertrophic cardiomyopathy (HCM) and arrhythmogenic right ventricular cardiomyopathy (ARVC). Subsequently, inverted T-waves may represent the first and only sign of an inherited heart muscle disease, in the absence of any other features and before structural changes in the heart can be detected. However, to date, there remains little evidence that deep T-wave inversions are always pathognomonic of either a cardiomyopathy or an ion channel disorder in an asymptomatic athlete following long-term follow-up. This paper aims to provide a systematic review of the prevalence of T-wave inversion in athletes and examine T-wave inversion and its relationship to structural heart disease, notably HCM and ARVC with a view to identify young athletes at risk of SCD during sport. Finally, the review proposes clinical management pathways (including genetic testing) for asymptomatic athletes demonstrating significant T-wave inversion with structurally normal hearts.

Purpose of review There has been much improvement in the treatment of heart failure over the past decade through the implementation of a multidisciplinary team approach to disease management focused on optimizing medication, the application of device-based therapy, surgical intervention and in promoting the education of patients and carers in self-management. This multidisciplinary strategy has now been extended to try and improve the care of those with advanced heart failure in the latter phases of the disease trajectory nearing the end of their lives. Recent findings A growing consensus has emerged in the literature that confirms the need to extend multidisciplinary management beyond the early targets of reducing heart failure-related mortality and morbidity to address the significant care needs of those who decline due to the often inexorable progression of this syndrome. Multidisciplinary management facilitates the development of a comprehensive care plan that is specifically tailored to accommodate the requirements of individual patients and their families and fosters a collaborative approach to care to optimize symptom management, avoid potential treatments conflicts, and to fulfil their supportive care needs. Partnership working between the three principal clinical disciplines of cardiology, specialist palliative care and general practice is central to this process and promotes coordinated care across hospital, hospice and community-based services. Summary Advanced heart failure management has improved over time; however, the incorporation of a multidisciplinary care model appears to offer significant promise in dealing with complex care needs of heart failure patients towards the end of life. Delivery of this practice requires the development of bespoke care structures that are relevant to the spectrum of healthcare service environments.

This study examined the cardiac structure and function of a unique cohort of documented lifelong, competitive endurance veteran athletes (>50 yr). Twelve lifelong veteran male endurance athletes [mean ± SD (range) age: 56 ± 6 yr (50–67)], 20 age-matched veteran controls [60 ± 5 yr; (52–69)], and 17 younger male endurance athletes [31 ± 5 yr (26–40)] without significant comorbidities underwent cardiac magnetic resonance (CMR) imaging to assess cardiac morphology and function, as well as CMR imaging with late gadolinium enhancement (LGE) to assess myocardial fibrosis. Lifelong veteran athletes had smaller left (LV) and right ventricular (RV) end-diastolic and end-systolic volumes ( P < 0.05), but maintained LV and RV systolic function compared with young athletes. However, veteran athletes had a significantly larger absolute and indexed LV and RV end-diastolic and systolic volumes, intraventricular septum thickness during diastole, posterior wall thickness during diastole, and LV and RV stroke volumes ( P < 0.05), together with significantly reduced LV and RV ejection fractions ( P < 0.05), compared with veteran controls. In six (50%) of the veteran athletes, LGE of CMR indicated the presence of myocardial fibrosis (4 veteran athletes with LGE of nonspecific cause, 1 probable previous myocarditis, and 1 probable previous silent myocardial infarction). There was no LGE in the age-matched veteran controls or young athletes. The prevalence of LGE in veteran athletes was not associated with age, height, weight, or body surface area ( P > 0.05), but was significantly associated with the number of years spent training ( P < 0.001), number of competitive marathons ( P < 0.001), and ultraendurance (>50 miles) marathons ( P < 0.007) completed. An unexpectedly high prevalence of myocardial fibrosis (50%) was observed in healthy, asymptomatic, lifelong veteran male athletes, compared with zero cases in age-matched veteran controls and young athletes. These data suggest a link between lifelong endurance exercise and myocardial fibrosis that requires further investigation.

Cardiomyopathies are a heterogeneous group of diseases of the myocardium associated with architectural abnormalities and mechanical dysfunction. Recent advances in our understanding of the genetics, pathophysiology, and natural history of these conditions has resulted in better diagnosis and management, leading to improvements in mortality. Major developments in imaging techniques, in particular contrast-enhanced MRI, now permit in vivo tissue characterization of the myocardium. Through defining disease severity, etiology, and to some extent in risk stratification, routine cardiovascular magnetic resonance evaluation of this group of patients provides essential information required in everyday clinical practice.

Background There are conflicting data on the usefulness of B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) in the optimization of therapy for heart failure (HF). Discordant results may be explained by the intra-individual variability of these peptides. This study evaluates the intraindividual variability of BNP and NT-proBNP and the impact of the covariates of age, sex, and renal function. Methods and Results Stable HF patients attending our unit were included. Blood samples were drawn 1 hour apart on 2 occasions 1 week apart. Forty-five patients were enrolled (69.6 ± 12.1 years, 64% male, 84% systolic HF). Within-hour and within-week intraindividual variability were: 6.9% and 21.1% for NT-proBNP; 14.6% and 28.4% for BNP (P < .01 for within-hour comparison of BNP and NT-proBNP). Reference change values over 1 week for NT-proBNP and BNP were 49.2% and 66.2%, respectively. There were no significant relationships identified between variability and age, gender, or glomerular filtration rate. Conclusion There is considerable intraindividual variability in these peptides in stable HF patients. Changes of approximately 50% and 66% for NT-proBNP and BNP from week to week are needed to indicate an altered clinical status and caution should be exercised in interpreting serial changes in these peptide levels when monitoring patient responses to treatment or clinical status.

We are pleased to address questions raised by Wheeler and colleagues concerning the identified high prevalence of hypertrophic cardiomyopathy (HCM) in our recent publication.1 The aim of our study was to prospectively determine the prevalence of cardiac pathology in athletes presenting with pathological T-wave inversion (PTWI), and to examine the efficacy of cardiac magnetic resonance in the further examination workup. Although Wheeler et al consider a PTWI prevalence of 2.4% high, it is nearly identical (2.3%) to that reported from a large, unselected population of 32 652 individuals.2 Indeed, ethnicity is known to impact T-wave inversion (TWI) rates, with black athletes and controls demonstrating TWI rates of 4.1% and 3.4% in the lateral leads only.3 Wheeler et al request outcome data in athletes with lone PTWI (ie, without ST …

Prevention of cardiovascular disease and heart failure (HF) in a cost-effective manner is a public health goal. This work aims to assess the cost-effectiveness of the St Vincent's Screening TO Prevent Heart Failure (STOP-HF) intervention.This is a substudy of 1054 participants with cardiovascular risk factors [median age 65.8 years, interquartile range (IQR) 57.8:72.4, with 4.3 years, IQR 3.4:5.2, follow-up]. Annual natriuretic peptide-based screening was performed, with collaborative cardiovascular care between specialist physicians and general practitioners provided to patients with BNP levels50 pg/mL. Analysis of cost per case prevented and cost-effectiveness per quality-adjusted life year (QALY) gained was performed. The primary clinical endpoint of LV dysfunction (LVD) with or without HF was reduced in intervention patients [odds ratio (OR) 0.60; 95% confidence interval (CI) 0.38-0.94; P = 0.026]. There were 157 deaths and/or emergency hospitalizations for major adverse cardiac events (MACE) in the control group vs. 102 in the intervention group (OR 0.68; 95% CI 0.49-0.93; P = 0.01). The cost per case of LVD/HF prevented was €9683 (sensitivity range -€843 to €20 210), whereas the cost per MACE prevented was €3471 (sensitivity range -€302 to €7245). Cardiovascular hospitalization savings offset increased outpatient and primary care costs. The cost per QALY gain was €1104 and the intervention has an 88% probability of being cost-effective at a willingness to pay threshold of €30 000.Among patients with cardiovascular risk factors, natriuretic peptide-based screening and collaborative care reduced LVD, HF, and MACE, and has a high probability of being cost-effective.NCT00921960.

Background: A number of studies have demonstrated the presence of a diabetic cardiomyopathy, increasing the risk of heart failure development in this population. Improvements in present-day risk factor control may have modified the risk of diabetes-associated cardiomyopathy. Aim: We sought to determine the contemporary impact of diabetes mellitus (DM) on the prevalence of cardiomyopathy in at-risk patients with and without adjustment for risk factor control. Design: A cross-sectional study in a population at risk for heart failure. Methods: Those with diabetes were compared to those with other cardiovascular risk factors, unmatched, matched for age and gender and then matched for age, gender, body mass index, systolic blood pressure and low density lipoprotein cholesterol. Results: In total, 1399 patients enrolled in the St Vincent’s Screening to Prevent Heart Failure (STOP-HF) cohort were included. About 543 participants had an established history of DM. In the whole sample, Stage B heart failure (asymptomatic cardiomyopathy) was not found more frequently among the diabetic cohort compared to those without diabetes [113 (20.8%) vs. 154 (18.0%), P = 0.22], even when matched for age and gender. When controlling for these risk factors and risk factor control Stage B was found to be more prevalent in those with diabetes [88 (22.2%)] compared to those without diabetes [65 (16.4%), P = 0.048]. Conclusion: In this cohort of patients with established risk factors for Stage B heart failure superior risk factor management among the diabetic population appears to dilute the independent diabetic insult to left ventricular structure and function, underlining the importance and benefit of effective risk factor control in this population on cardiovascular outcomes.

Purpose This case illustrates an acute myocardial infarction with occlusion of the left anterior descending coronary artery complicated by apical ventricular rupture and apical thrombus. Procedures An electrocardiogram, transthoracic echocardiogram (TTE), coronary angiography and cardiac magnetic resonance imaging (CMR) guided optimal management of the patient. Findings Coronary angiography revealed multivessel disease with an ostial occlusion of the LAD. Echocardiography showed apical dilatation of the left ventricle with a large, echogenic mass at the apex. Contrast echocardiography confirmed the presence of a large apical thrombus, separated from the LV cavity by myocardium. A CMR showed a completed LAD infarct and a filling thrombus was noted in the aneurysmal apical region inferring a contained rupture of the LV apex. Principle Conclusions Accurate and definitive delineation of unusual cardiac anatomy is best provided by complementary multimodality cardiac imaging, echocardiography and CMR. TTE can miss LV thrombi, particularly when they are large, aneurysmal and apical in nature. CMR provides the cardiac surgeon the ability to visualise in 3D the functional and morphological abnormalities, helping guide necessary intervention. Optimal management of patients with ventricular rupture remains controversial both in terms of timing and choice of intervention.

Myocardial fibrosis identified by late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) in patients with hypertrophic cardiomyopathy (HCM) is associated with adverse cardiovascular events, but its value as an independent risk factor for sudden cardiac death (SCD) is unknown. We investigated the role of LGE-CMR in the risk stratification of HCM.We conducted a prospective cohort study in a tertiary referral centre. Consecutive patients with HCM (n=711, median age 56.3 years, IQR 46.7-66.6; 70.0% male) underwent LGE-CMR and were followed for a median 3.5 years. The primary end point was SCD or aborted SCD.Overall, 471 patients (66.2%) had myocardial fibrosis (median 5.9% of left ventricular mass, IQR: 2.2-13.3). Twenty-two (3.1%) reached the primary end point. The extent but not the presence of fibrosis was a significant univariable predictor of the primary end point (HR per 5% LGE: 1.24, 95% CI 1.06 to 1.45; p=0.007 and HR for LGE: 2.69, 95% CI 0.91 to 7.97; p=0.073, respectively). However, on multivariable analysis, only LV-EF remained statistically significant (HR: 0.92, 95% CI 0.89 to 0.95; p0.001). For the secondary outcome of cardiovascular mortality/aborted SCD, the presence and the amount of fibrosis were significant predictors on univariable but not multivariable analysis after adjusting for LV-EF and non-sustained ventricular tachycardia.The amount of myocardial fibrosis was a strong univariable predictor of SCD risk. However, this effect was not maintained after adjusting for LV-EF. Further work is required to elucidate the interrelationship between fibrosis and traditional predictors of outcome in HCM.

Aims Heart failure has been demonstrated in previous studies to have a dismal prognosis. However, the modern-day prognosis of patients with new onset heart failure diagnosed in the community managed within a disease management programme is not known. The purpose of this study is to report on prognosis of patients presenting with new onset heart failure in the community who are subsequently followed in a disease management program. Methods and Results A review of patients referred to a rapid access heart failure diagnostic clinic between 2002 and 2012 was undertaken. Details of diagnosis, demographics, medical history, medications, investigations and mortality data were analysed. A total of 733 patients were seen in Rapid Access Clinic for potential new diagnosis of incident of heart failure. 38.9% (n=285) were diagnosed with heart failure, 40.7% (n=116) with HF-REF and 59.3% (n=169) with HF-PEF. There were 84 (29.5%) deaths in the group of patients diagnosed with heart failure; 41 deaths (35.3%) occurred in patients with HF-REF and 43 deaths (25.4%) occurred in patients with HF-PEF. In patients with heart failure, 52.4% (n=44) died from cardiovascular causes. 63.8% of HF patients were alive after 5 years resulting on average in a month per year loss of life expectancy over that period compared with aged matched simulated population. Conclusions In this community-based cohort, the prognosis of heart failure was better than reported in previous studies. This is likely due to the impact of prompt diagnosis, the improvement in therapies and care within a disease management structure.

This case is of a 29-year-old man with progressive familial intrahepatic cholestasis type 1 also known as Byler9s disease. At the age of 21, our patient developed non-ischaemic dilated cardiomyopathy. Cardiac MRI demonstrated global wall thinning, with significant areas of myocardial fibrosis in the mid and epicardial walls from base to apex on postgadolinium late contrast enhanced images. No shared genetic loci between dilated cardiomyopathy and Byler9s or cholestatic liver disease have yet been found. This presents the first documented case of non-ischaemic dilated cardiomyopathy, with evidence of mid wall fibrosis, in association with an established diagnosis of progressive familial intrahepatic cholestasis type 1 since childhood.

Background— Aspirin use in heart failure (HF) is controversial. The drug has proven benefit in comorbidities associated with HF; however, retrospective analysis of angiotensin-converting enzyme inhibitor trials and prospective comparisons with warfarin have shown increased risk of morbidity with aspirin use. This study aims to evaluate the association of low-dose aspirin with mortality and morbidity risk in a large community-based cohort. Methods and Results— This was a retrospective cohort study of patients attending an HF disease management program. Aspirin use at baseline and its association with mortality and HF hospitalization in the population was examined. Of 1476 patients (mean age, 70.4±12.4 years; 63% men), 892 (60.4%) were prescribed aspirin. Low-dose aspirin (75 mg/d) was prescribed to 828 (92.8%) patients. Median follow-up time was 2.6 (0.8–4.5) years. During the follow-up period, 464 (31.4%) patients died. In adjusted analysis, low-dose aspirin use was associated with reduced mortality risk compared with nonaspirin use (hazard ratio=0.58; 95% confidence interval, 0.46–0.74), and this was confirmed by a propensity-matched subgroup analysis. Low-dose aspirin use was associated with reduced risk of HF hospitalization compared with nonaspirin use in the total population (adjusted hazard ratio=0.70; 95% confidence interval, 0.54–0.90). In adjusted analysis, there was no difference in mortality or HF hospitalization between high-dose aspirin users (>75 mg/d) and nonaspirin users. Conclusions— In this study, low-dose aspirin therapy was associated with a significant reduction in mortality and morbidity risk during long-term follow-up. These results suggest that low-dose aspirin may have a continuing role in secondary prevention in HF and underline the need for more trials of low-dose aspirin use in HF.

Background Microvascular dysfunction in HCM has been associated with adverse clinical outcomes. Advances in quantitative cardiovascular magnetic resonance (CMR) perfusion imaging now allow myocardial blood flow to be quantified at the pixel level. We applied these techniques to investigate the spectrum of microvascular dysfunction in hypertrophic cardiomyopathy (HCM) and to explore its relationship with fibrosis and wall thickness. Methods CMR perfusion imaging was undertaken during adenosine-induced hyperemia and again at rest in 35 patients together with late gadolinium enhancement (LGE) imaging. Myocardial blood flow (MBF) was quantified on a pixel-by-pixel basis from CMR perfusion images using a Fermi-constrained deconvolution algorithm. Regions-of-interest (ROI) in hypoperfused and hyperemic myocardium were identified from the MBF pixel maps. The myocardium was also divided into 16 AHA segments. Results Resting MBF was significantly higher in the endocardium than in the epicardium (mean ± SD: 1.25 ± 0.35 ml/g/min versus 1.20 ± 0.35 ml/g/min, P

A 50-year-old asymptomatic man was referred for cardiovascular magnetic resonance after the incidental finding of a mediastinal mass on echocardiography. In particular, the echocardiogram showed a mediastinal mass (6.5×10 cm) close to the right side of the heart without clear infiltration. Left and right ventricular function was normal. The chest x-ray showed the right-sided mediastinal mass obliterating the right heart border, with normal lung parenchyma. The ECG (Figure 1) showed sinus rhythm with normal atrioventricular conduction, left axis deviation, normal intraventricular conduction, and normal repolarization. The cardiac magnetic resonance confirmed the presence of a large encapsulated mediastinal mass (Figure 2) located superiorly in the right anterior mediastinum, adjacent to the ascending aortic wall, the superior vena cava, and the junction of the right ventricle outflow tract with the main pulmonary trunk. There was some compression of the right upper pulmonary vein but no …

In patients with symptoms of heart failure, identifying the underlying cause of cardiomyopathy is helpful to establish the diagnosis and to guide therapy. The differential diagnosis of cardiomyopathy can be challenging based on clinical findings. We report the case of a patient who represented a clinical dilemma (cardiac sarcoidosis or ischaemic heart disease), in whom cardiovascular magnetic resonance was a clinically valuable tool to distinguish dual cardiac pathology due to its unique, non-invasive, tissue characterization capabilities.

Risk stratification of patients with nonischemic dilated cardiomyopathy is primarily based on left ventricular ejection fraction (LVEF). Superior prognostic factors may improve patient selection for implantable cardioverter-defibrillators (ICDs) and other management decisions.To determine whether myocardial fibrosis (detected by late gadolinium enhancement cardiovascular magnetic resonance [LGE-CMR] imaging) is an independent and incremental predictor of mortality and sudden cardiac death (SCD) in dilated cardiomyopathy.Prospective, longitudinal study of 472 patients with dilated cardiomyopathy referred to a UK center for CMR imaging between November 2000 and December 2008 after presence and extent of midwall replacement fibrosis were determined. Patients were followed up through December 2011.Primary end point was all-cause mortality. Secondary end points included cardiovascular mortality or cardiac transplantation; an arrhythmic composite of SCD or aborted SCD (appropriate ICD shock, nonfatal ventricular fibrillation, or sustained ventricular tachycardia); and a composite of HF death, HF hospitalization, or cardiac transplantation.Among the 142 patients with midwall fibrosis, there were 38 deaths (26.8%) vs 35 deaths (10.6%) among the 330 patients without fibrosis (hazard ratio [HR], 2.96 [95% CI, 1.87-4.69]; absolute risk difference, 16.2% [95% CI, 8.2%-24.2%]; P.001) during a median follow-up of 5.3 years (2557 patient-years of follow-up). The arrhythmic composite was reached by 42 patients with fibrosis (29.6%) and 23 patients without fibrosis (7.0%) (HR, 5.24 [95% CI, 3.15-8.72]; absolute risk difference, 22.6% [95% CI, 14.6%-30.6%]; P.001). After adjustment for LVEF and other conventional prognostic factors, both the presence of fibrosis (HR, 2.43 [95% CI, 1.50-3.92]; P.001) and the extent (HR, 1.11 [95% CI, 1.06-1.16]; P.001) were independently and incrementally associated with all-cause mortality. Fibrosis was also independently associated with cardiovascular mortality or cardiac transplantation (by fibrosis presence: HR, 3.22 [95% CI, 1.95-5.31], P.001; and by fibrosis extent: HR, 1.15 [95% CI, 1.10-1.20], P.001), SCD or aborted SCD (by fibrosis presence: HR, 4.61 [95% CI, 2.75-7.74], P.001; and by fibrosis extent: HR, 1.10 [95% CI, 1.05-1.16], P.001), and the HF composite (by fibrosis presence: HR, 1.62 [95% CI, 1.00-2.61], P = .049; and by fibrosis extent: HR, 1.08 [95% CI, 1.04-1.13], P.001). Addition of fibrosis to LVEF significantly improved risk reclassification for all-cause mortality and the SCD composite (net reclassification improvement: 0.26 [95% CI, 0.11-0.41]; P = .001 and 0.29 [95% CI, 0.11-0.48]; P = .002, respectively).Assessment of midwall fibrosis with LGE-CMR imaging provided independent prognostic information beyond LVEF in patients with nonischemic dilated cardiomyopathy. The role of LGE-CMR in the risk stratification of dilated cardiomyopathy requires further investigation.

Background The goal of treating patients with coronary artery disease is to improve survival and relieve symptoms. Several studies have compared the safety and efficacy of left main coronary artery (LMCA) stenting and coronary-artery bypass grafting in case control and randomized trials. Objective In this study we present the long term outcome of stenting unprotected LMCA stenosis in day to day practice in unselected patients. Methods One hundred and fifty eight patients were prospectively recruited with symptomatic unprotected LMCA stenosis undergoing percutaneous coronary intervention (PCI). Using the euroSCORE, each patient's surgical mortality risk was estimated. Study end-points were any major adverse cardiac event (MACE) defined as cardiac death, nonfatal myocardial infarction, or target lesion revascularization at follow-up with either CABG or repeat PCI. Results The mean follow-up was 54 ± 25 months. The mean euroSCORE was 10.6 ± 13.4 (0.9–71) and the mean SYNTAX score was 39.6 ± 10.7 (10–65). The MACE rate was 11.4% at a mean follow up of 54 months. Six (3.8%) patients suffered postprocedure myocardial infarction. There were 24 (15%) deaths of which 12 were cardiac (mean euroSCORE 21.6 ± 5.5 P

The authors present a case of an 81-year-old man with fever of unknown origin. The case report is illustrated with the images which clarified the diagnosis in this challenging case. The cardiac MR images were of critical importance in arriving at a diagnosis of aortic root mycotic pseudoaneurysm with rupture into the right ventricle.

International audience; AIM: Differentiating physiological cardiac hypertrophy from pathology is challenging when the athlete presents with extreme anthropometry. While upper normal limits exist for maximal left ventricular (LV) wall thickness (14 mm) and LV internal diameter in diastole (LVIDd, 65 mm), it is unknown if these limits are applicable to athletes with a body surface area (BSA) >2.3 m(2). PURPOSE: To investigate cardiac structure in professional male athletes with a BSA>2.3 m(2), and to assess the validity of established upper normal limits for physiological cardiac hypertrophy. METHODS: 836 asymptomatic athletes without a family history of sudden death underwent ECG and echocardiographic screening. Athletes were grouped according to BSA (Group 1, BSA>2.3 m(2), n=100; Group 2, 2-2.29 m(2), n=244; Group 3, 13 mm, but in combination with an abnormal ECG suspicious of an inherited cardiac disease. CONCLUSION: Regardless of extreme anthropometry, established upper limits for physiological cardiac hypertrophy of 14 mm for maximal wall thickness and 65 mm for LVIDd are clinically appropriate for all athletes. However, the abnormal ECG is key to diagnosis and guides follow-up, particularly when cardiac dimensions are within accepted limits.

Aims Limited data are available concerning the evolution of the left atrial volume index (LAVI) in pre-heart failure (HF) patients. The aim of this study was to investigate clinical characteristics and serological biomarkers in a cohort with risk factors for HF and evidence of serial atrial dilatation. Methods and results This was a prospective substudy within the framework of the STOP-HF cohort (NCT00921960) involving 518 patients with risk factors for HF electively undergoing serial clinical, echocardiographic, and natriuretic peptide assessment. Mean follow-up time between assessments was 15 ± 6 months. ‘Progressors’ (n = 39) were defined as those with serial LAVI change ≥3.5 mL/m2 (and baseline LAVI between 20 and 34 mL/m2). This cut-off was derived from a calculated reference change value above the biological, analytical, and observer variability of serial LAVI measurement. Multivariate analysis identified significant baseline clinical associates of LAVI progression as increased age, beta-blocker usage, and left ventricular mass index (all P < 0.05). Serological biomarkers were measured in a randomly selected subcohort of 30 ‘Progressors’ matched to 30 ‘Non-progressors’. For ‘Progressors’, relative changes in matrix metalloproteinase 9 (MMP9), tissue inhibitor of metalloproteinase 1 (TIMP1), and the TIMP1/MMP9 ratio, markers of interstitial remodelling, tracked with changes in LAVI over time (all P < 0.05). Conclusion Accelerated LAVI increase was found to occur in up to 14% of all pre-HF patients undergoing serial echocardiograms over a relatively short follow-up period. In a randomly selected subcohort of ‘Progressors’, changes in LAVI were closely linked with alterations in MMP9, TIMP1, and the ratio of these enzymes, a potential aid in highlighting this at-risk group.

Summary To estimate the cost and diagnostic implications of using CMR alone instead of conventional TTE/TMET work-up to guide patient selection for angiography. Healthcare costs were derived from VHI’s hospital billing system. Background Patient selection for coronary angiography traditionally relies on clinical assessment, treadmill exercise testing (TMET) and transthoracic echocardiography (TTE). Cardiac Magnetic Resonance (CMR) is a relatively novel imaging study, which provides excellent non-invasive assessment of myocardial perfusion and is useful in risk stratification of patients with suspected coronary artery disease (CAD). Methods