Cardiac magnetic resonance in ischemic cardiomyopathy: present role and future directions

Ischemic cardiomyopathy is a significant cause of mortality and morbidity, with peculiar needs for accurate diagnostic and prognostic characterization. Cardiac magnetic resonance (CMR) can help to satisfy these requirements by allowing a comprehensive evaluation of myocardial function, perfusion and tissue composition, with a demonstrated utility in guiding clinical management of patients with known or suspected ischemic cardiomyopathy. When compared with alternative non-invasive imaging modalities, such as stress echocardiography and nuclear techniques, CMR is able to provide accurate (function and perfusion) or peculiar (tissue characterization) information on cardiac pathophysiology, while avoiding exposition to ionizing radiations and overcoming limitations related to the quality of the imaging window. In particular, stress perfusion CMR showed to be accurate, safe, cost-effective, and clinically valuable as a non-invasive test for detecting severity and distribution of myocardial ischemia. In many circumstances, however, local availability of the technique, together with procedural costs, and scanning and post-processing time duration still limit the use of CMR in clinical routine. In the current review, we focused on clinical applications of CMR in ischemic cardiomyopathy. The consolidated role of the technique is described by illustrating both standard and advanced sequences that constitute the current body of a dedicated CMR examination. Ongoing developments and potential future diagnostic and prognostic applications of CMR when assessing ischemic cardiomyopathy are also discussed, with a focus on artificial intelligence-based implementations proposed for refining the efficiency of CMR analysis and reporting.