Background
Methods
Nr. | Title | Year | Role of CMR |
---|---|---|---|
1 | ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death [6] | 2015 | 1 |
2 | ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension [7] | 2015 | 2 |
3 | ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation [9] | 2015 | 1 |
4 | ESC Guidelines for the diagnosis and management of pericardial diseases [11] | 2015 | 1 |
5 | ESC Guidelines for the management of infective endocarditis [12] | 2015 | 1 |
6 | ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy [14] | 2014 | 1 |
7 | ESC Guidelines on the diagnosis and treatment of aortic diseases [15] | 2014 | 1 |
8 | ESC/EACTS Guidelines on myocardial revascularization [16] | 2014 | 1 |
9 | ESC Guidelines on the diagnosis and management of acute pulmonary embolism [17] | 2014 | 1 |
10 | ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management [18] | 2014 | 1 |
11 | ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD [19] | 2013 | 2 |
12 | ESC guidelines on the management of stable coronary artery disease [20] | 2013 | 1 |
13 | ESC Guidelines on cardiac pacing and cardiac resynchronization therapy [21] | 2013 | 2 |
14 | ESH/ESC Guidelines for the management of arterial hypertension [22] | 2013 | 1 |
15 | ESC/EACTS Guidelines on the management of valvular heart disease [23] | 2012 | 2 |
16 | Focused update of the ESC Guidelines for the management of atrial fibrillation [24] | 2012 | 3 |
17 | ESC/ACCF/AHA/WHF Third universal definition of myocardial infarction [25] | 2012 | 2 |
18 | ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation [26] | 2012 | 1 |
19 | ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure [27] | 2012 | 1 |
20 | European Guidelines on cardiovascular disease prevention in clinical practice [28] | 2012 | 2 |
21 | ESC/EAS Guidelines for the management of dyslipidaemias [29] | 2011 | 3 |
22 | ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation [10] | 2011 | (new guideline 2015) |
23 | ESC Guidelines on the management of cardiovascular diseases during pregnancy [30] | 2011 | 1 |
24 | ESC Guidelines on the diagnosis and treatment of peripheral artery diseases [31] | 2011 | 1 |
25 | ESC Guidelines for the management of grown-up congenital heart disease [32] | 2010 | 2 |
26 | Focused Update of ESC Guidelines on device therapy in heart failure [34] | 2010 | 3 |
27 | Guidelines on the prevention, diagnosis, and treatment of infective endocarditis [23] | 2009 | (new guideline 2015) |
28 | Guidelines for the diagnosis and management of syncope [35] | 2009 | 2 |
29 | Guidelines for the diagnosis and treatment of pulmonary hypertension [8] | 2009 | (new guideline 2015) |
Class of recommendation | Definition | Suggested wording to use |
---|---|---|
Class I | Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective. | Is recommended/is indicated |
Class II | Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure. | |
Class IIa | Weight of evidence/opinion is in favour of usefulness/efficacy. | Should be considered |
Class IIb | Usefulness/efficacy is less well established by evidence/opinion. | May be considered |
Class III | Evidence or general agreement that the given treatment or procedure is not useful/effective, and in some cases may be harmful. | Is not recommended |
Level of evidence A | Data derived from multiple randomized clinical trials or meta-analyses. |
Level of evidence B | Data derived from a single randomized clinical trial or large non-randomized studies. |
Level of evidence C | Consensus of opinion of the experts and/or small studies, retrospective studies, registries. |
Results
Non-invasive evaluation of patients with suspected or known ventricular arrhythmias | Classa
| Levelb
| Page |
Pharmacological stress testing plus imaging modality is recommended to detect silent ischaemia in patients with ventricular arrhythmias who have an intermediate probability of having coronary artery disease by age or symptoms and are physically unable to perform a symptom-limited exercise test. | I | B | 12 |
CMR or CT should be considered 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 | 12 |
Management of ventricular arrhythmias in inflammatory heart disease | Classa
| Levelb
| Page |
Demonstration of persistent myocardial inflammatory infiltrates by immunohistological evidence and/or abnormal localized fibrosis by CMR after acute myocarditis may be considered as an additional indicator of increased risk of SCD in inflammatory heart disease. | IIb | C | 53 |
Prevention of sudden cardiac death in athletes | Classa
| Levelb
| Page |
Upon identification of ECG abnormalities suggestive of structural heart disease, echocardiography and/or CMR imaging is recommended. | I | C | 62 |
2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death [6]
Recommendations for imaging in patients with suspected non-ST-elevation acute coronary syndromes | Classa
| Levelb
| Page |
---|---|---|---|
In patients with no recurrence of chest pain, normal ECG findings and normal levels of cardiac troponin (preferably high-sensitivity), but suspected acute coronary syndrome, a non-invasive stress test (preferably with imaging) for inducible ischaemia is recommended before deciding on an invasive strategy. | I | A | 15 |
2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension [7]
2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation [9]
Recommendation for diagnostic work-up of pericardial diseases | Classa
| Levelb
| Page |
CT and/or CMR are second-level testing for diagnostic workup in pericarditis | I | C | 38 |
Recommendations for the diagnosis and management of pericarditis associated with myocarditis | Classa
| Levelb
| Page |
CMR is recommended for the confirmation of myocardial involvement | I | C | 13 |
Recommendations for the diagnosis of pericardial effusion | Classa
| Levelb
| Page |
CT or CMR should be considered in suspected cases of loculated pericardial effusion, pericardial thickening and masses, as well as associated chest abnormalities | IIa | C | 14 |
Recommendations for the diagnosis of constrictive pericarditis | Classa
| Levelb
| Page |
CT and/or CMR are indicated as second-level imaging techniques to assess calcifications (CT), pericardial thickness, degree and extension of pericardial involvement | I | C | 17 |
Recommendations for therapy of constrictive pericarditis | Classa
| Levelb
| Page |
Empiric anti-inflammatory therapy may be considered in cases with transient or new diagnosis of constriction with concomitant evidence of pericardial inflammation (i.e. CRP elevation or pericardial enhancement on CT/CMR) | IIb | C | 19 |
2015 ESC guidelines for the diagnosis and management of pericardial diseases [11]
Recommendations for CMR in patients with HCM | Classa
| Levelb
| Page |
---|---|---|---|
It is recommended that CMR studies be performed and interpreted by teams experienced in cardiac imaging and in the evaluation of heart muscle disease | I | B | 14 |
In the absence of contraindications, CMR with LGE is recommended in patients with suspected HCM who have inadequate echocardiographic windows, in order to confirm the diagnosis. | I | C | 14 |
In the absence of contraindications, CMR with LGE should be considered in patients fulfilling diagnostic criteria for HCM, to assess cardiac anatomy, ventricular function, and the presence and extent of myocardial fibrosis. | IIa | B | 14 |
CMR with LGE imaging should be considered in patients with suspected apical hypertrophy or aneurysm. | IIa | C | 14 |
CMR with LGE imaging should be considered in patients with suspected cardiac amyloidosis. | IIa | C | 14 |
CMR with LGE may be considered before septal alcohol ablation or myectomy, to assess the extent and distribution of hypertrophy and myocardial fibrosis. | IIb | C | 14 |
CMR may be considered every 5 years in clinically stable patients, or every 2–3 years in patients with progressive disease. | IIb | C | 37 |
2015 ESC guidelines for the management of infective endocarditis [12]
2014 ESC guidelines on diagnosis and management of hypertrophic cardiomyopathy [14]
Recommendations on diagnostic work-up of acute aortic syndrome | Classa
| Levelb
| Page |
In stable patients with a suspicion of acute aortic syndrome, CMR is recommended (or should be considered) according to local availability and expertise | I | C | 22 |
In case of initially negative imaging with persistence of suspicion of acute aortic syndrome, repetitive imaging (CT or CMR) is recommended. | I | C | 22 |
In case of uncomplicated Type B aortic dissection treated medically, repeated imaging (CT or CMR) during the first days is recommended. | I | C | 22 |
In uncomplicated Type B intramural hematoma, repetitive imaging (CMR or CT) is indicated. | I | C | 26 |
In uncomplicated Type B penetrating aortic ulcer, repetitive imaging (CMR or CT) is indicated. | I | C | 27 |
Recommendations for the management of aortic root dilation in patients with bicuspid aortic valve | Classa
| Levelb
| Page |
CMR or CT is indicated in patients with bicuspid aortic valve when the morphology of the aortic root and the ascending aorta cannot be accurately assessed by TTE. | I | C | 42 |
In the case of aortic diameter >50 mm or an increase >3 mm/year measured by echocardiography, confirmation of the measurement is indicated, using another imaging modality (CT or CMR). | I | C | 42 |
Recommendations for follow-up and management in chronic aortic diseases | Classa
| Levelb
| Page |
Contrast CT or CMR is recommended to confirm the diagnosis of chronic aortic dissection. | I | C | 48 |
For follow-up after (T)EVAR in young patients, CMR should be preferred to CT for magnetic resonance-compatible stent grafts, to reduce radiation exposure. | IIa | C | 48 |
2014 ESC guidelines on the diagnosis and treatment of aortic diseases [15]
Recommendations for imaging to determine ischemia to plan revascularization | Classa
| Levelb
| Page |
Stress CMR, stress-echo, SPECT or PET are recommended in subjects with intermediate pretest probability for suspected coronary artery disease and stable symptoms | I | A | 14 |
To achieve a prognostic benefit by revascularization in patients with coronary artery disease, ischemia has to be documented by non-invasive imaging | |||
Left main disease with stenosis >50 % | I | A | 18 |
Any proximal LAD stenosis >50 % | I | A | 18 |
Two-vessel or three-vessel disease with stenosis > 50 % with impaired LV function (LVEF < 40 %)a | I | A | 18 |
Large area of ischaemia (>10 % LV) | I | B | 18 |
Single remaining patent coronary artery with stenosis >50 % | I | C | 18 |
Recommendations for follow-up and management after myocardial revascularization for asymptomatic patients | Classa
| Levelb
| Page |
Early imaging testing should be considered in specific patient subsets. | IIa | C | 72 |
Routine stress testing may be considered >2 years after PCI and >5 years after CABG. | IIa | B | 72 |
Recommendations for follow-up and management after myocardial revascularization for symptomatic patients | Classa
| Levelb
| Page |
It is recommended to reinforce medical therapy and lifestyle changes in patients with low-risk findings at stress testing. | I | C | 72 |
With intermediate- to high-risk findings at stress testing, coronary angiography is recommended. | I | C | 72 |
Recommendation for carotid artery screening before CABG | Classa
| Levelb
| Page |
CMR, CT, or digital subtraction angiography may be considered if carotid artery stenosis by ultrasound is >70 % and myocardial revascularization is contemplated. | IIb | C | 39 |
2014 ESC/EACTS guidelines on myocardial revascularization [16]
Recommendations for CMR in pulmonary embolism | Classa
| Levelb
| Page |
---|---|---|---|
MR angiography should not be used to rule out pulmonary embolism. | III | C | 11 |
2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism [17]
Recommendations for non-invasive stress testing of ischemic heart disease | Classa
| Levelb
| Page |
---|---|---|---|
Imaging stress testing is recommended before high-risk surgery in patients with more than two clinical risk factors and poor functional capacity (<4 METs). | I | C | 12 |
Imaging stress testing may be considered before high- or intermediate-risk surgery in patients with one or two clinical risk factors and poor functional capacity (<4 METs). | IIb | C | 12 |
Imaging stress testing is not recommended before low-risk surgery, regardless of the patient’s clinical risk. | III | C | 12 |
2014 ESC/ESA guidelines on non-cardiac surgery: cardiovascular assessment and management [18]
Recommendations for non-invasive testing for ischemic heart disease | Classa
| Levelb
| Page |
In patients with suspected stable coronary artery disease and intermediate pretest probability of 15 % - 65 % and LVEF ≥50 %, stress imaging is preferred as the initial test option if local expertise and availability permit. | I | B | 17 |
An imaging stress test is recommended as the initial test for diagnosing stable coronary artery disease if the pretest probability is between 66-85 % or if LVEF is <50 % in patients without typical angina. | I | B | 17 |
An imaging stress test is recommended in patients with resting ECG abnormalities, which prevent accurate interpretation of ECG changes during stress. | I | B | 17 |
An imaging stress test should be considered in symptomatic patients with prior revascularization (PCI or CABG). | IIa | B | 17 |
An imaging stress test should be considered to assess the functional severity of intermediate lesions on coronary arteriography. | IIa | B | 17 |
Recommendations for risk stratification using ischemia testing | Classa
| Levelb
| Page |
Risk stratification is recommended based on clinical assessment and the results of the stress test initially employed for making a diagnosis of stable coronary artery disease | I | B | 22 |
Stress imaging for risk stratification is recommended in patients with a non-conclusive exercise ECG | I | B | 22 |
Risk stratification using stress ECG (unless they cannot exercise or display ECG changes which make the ECG non evaluable) or preferably stress imaging if local expertise and availability permit is recommended in patients with stable coronary disease after a significant change in symptom level | I | B | 22 |
Stress imaging is recommended for risk stratification in patients with known stable coronary artery disease and a deterioration in symptoms if the site and extent of ischemia would influence clinical decision making | I | B | 22 |
In asymptomatic adults with diabetes or asymptomatic adults with a strong family history of coronary artery disease or when previous risk assessment testing suggests high risk of coronary artery disease, such as a coronary artery calcium score of 400 or greater stress imaging tests (MPI, stress echocardiography, perfusion CMR) may be considered for advanced cardiovascular risk assessment. | IIb | C | 24 |
Recommendation for re-assessment in patients with stable coronary artery disease | Classa
| Levelb
| Page |
An exercise ECG or stress imaging if appropriate is recommended in the presence of recurrent or new symptoms once instability has been ruled out. | I | C | 25 |
Reassessment of the prognosis using stress testing may be considered in asymptomatic patients after the expiration of the period for which the previous test was felt to be valid (“warranty period”) | IIb | C | 25 |
In symptomatic patients with revascularized stable coronary artery disease, stress imaging (stress echocardiography, CMR or MPS) is indicated rather than stress ECG. | I | C | 47 |
Late (6 months) stress imaging test after revascularization may be considered to detect patients with restenosis after stenting or graft occlusion irrespective of symptoms. | IIb | C | 47 |
2013 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD [19]
2013 ESC guidelines on the management of stable coronary artery disease [20]
Recommendations for stress-testing in arterial hypertension | Classa
| Levelb
| Page |
---|---|---|---|
Whenever history suggests myocardial ischaemia, a stress ECG test is recommended, and, if positive or ambiguous, an imaging stress test (stress echocardiography, stress CMR or nuclear scintigraphy) is recommended. | I | C | 21 |
2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy [21]
2013 ESH/ESC guidelines for the management of arterial hypertension [22]
Recommendations for imaging during hospitalization and at discharge in patients with STEMI | Classa
| Levelb
| Page |
---|---|---|---|
If echocardiography is not feasible, CMR may be used as an alternative for assessment of infarct size and resting LV function. | IIb | C | 26 |
For patients with multivessel disease, or in whom revascularization of other vessels is considered, stress testing or imaging (e.g. using stress myocardial perfusion scintigraphy, stress echocardiography, positron emission tomography or CMR) for ischaemia and viability is indicated before or after discharge. | I | A | 26 |
2012 guidelines on the management of valvular heart disease [23]
2012 focused update of the ESC Guidelines for the management of atrial fibrillation [24]
2012 third universal definition of myocardial infarction [25]
2012 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation [26]
Recommendations for CMR in ambulatory patients suspected of having heart failure | Classa
| Levelb
| Page |
---|---|---|---|
CMR imaging is recommended to evaluate cardiac structure and function, to measure LVEF, and to characterize cardiac tissue, especially in subjects with inadequate echocardiographic images or where the echocardiographic findings are inconclusive or incomplete (but taking account of cautions/contraindications to CMR). | I | C | 10 |
Myocardial perfusion/ischaemia imaging (echocardiography, CMR, SPECT, or PET) should be considered in patients thought to have coronary artery disease, and who are considered suitable for coronary revascularization, to determine whether there is reversible myocardial ischaemia and viable myocardium. | IIa | C | 10 |
2012 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure [27]
Recommendations | Classa
| Levelb
| Page |
---|---|---|---|
CMR (without gadolinium) should be considered if echocardiography is insufficient for diagnosis. | IIa | C | 14 |
Imaging of the entire aorta (CT/CMR) should be performed before pregnancy in patients with Marfan syndrome or other known aortic disease. | I | C | 22 |
For imaging of pregnant women with dilatation of the distal ascending aorta, aortic arch or descending aorta, CMR (without gadolinium) is recommended. | I | C | 22 |
2012 European guidelines on cardiovascular disease prevention in clinical practice [28]
2011 ESC/EAS guidelines for the management of dyslipidaemias [29]
2011 ESC guidelines on the management of cardiovascular diseases during pregnancy [30]
Recommendations for evaluation of carotid artery stenosis | Classa
| Levelb
| Page |
Duplex ultrasound, CT-angiography, and/or MRA are indicated to evaluate carotid artery stenosis. | I | A | 11 |
Recommendations for diagnosis of symptomatic chronic mesenteric ischaemia | Classa
| Levelb
| Page |
When Duplex ultrasound is inconclusive, CT-angiography or gadolinium-enhanced MRA are indicated. | I | B | 19 |
Recommendations for diagnostic strategies for renal artery stenosis | Classa
| Levelb
| Page |
MRA (in patients with creatinine clearance >30 mL/min) is recommended to establish the diagnosis of renal artery stenosis. | I | B | 21 |
Recommendations for diagnostic tests in patients with lower extremity artery disease | Classa
| Levelb
| Page |
Duplex ultrasound and/or CT-angiography and/or MRA are indicated to localize lower extremity artery disease lesions and consider revascularization options. | I | A | 26 |