Coronary artery disease (CAD) remains the leading cause of death in the United States and Europe. Although there has been a decline in the number of deaths from myocardial infarction throughout the western world, the mortality for congestive heart failure has more than doubled. Importantly, CAD accounts for the majority (almost 70%) of congestive heart failure cases.

In the clinical management of patients with congestive heart failure caused by CAD, the accurate assessment of myocardial viability is crucial to guide treatment; this is because revascularisation of dysfunctional but viable myocardium can improve ventricular function and long-term survival.

Another everyday clinical scenario is the risk stratification of patients suspected to have CAD presenting for work up of chest pain syndromes. If left ventricular function is normal, stress testing remains the primary approach for detecting myocardial ischaemia.

Traditionally nuclear imaging, stress echocardiography and (stress) electrocardiography have been the clinical mainstays for assessing myocardial viability as well as to detect myocardial ischaemia. However, cardiovascular MR (CMR) is a rapidly emerging non-invasive imaging technique, providing high-resolution images of the heart in any desired plane and without radiation. Rather than a single technique, CMR consists of several techniques that can be performed separately or in various combinations during a patient examination. For example, cine-CMR can provide assessment of cardiac morphology, function and contractile reserve; perfusion CMR with and without vasodilators can provide assessment of myocardial perfusion reserve, and contrast enhanced CMR (ceCMR) can be used for infarct detection as well as non-invasive tissue characterisation.

This article will review the potential of CMR for managing patients with known or suspected CAD by discussing different CMR techniques for assessment of myocardial viability and myocardial ischaemia.

ASSESSMENT OF MYOCARDIAL VIABILITY

The most precise definition of infarction, and therefore the loss of viability, is that myocyte death must have occurred. All ischaemic events …