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The demand for cardiac MRI scans is on a steady rise, experts showed at the SERAM2024 meeting last week in Barcelona. The technique has become crucial for cardiology daily practice, but must overcome challenges such as equipment accessibility, a limited number of trained physicians, and reimbursement, according to a prominent UK-based Italian cardiologist, Mélisande Rouger reports.

There are many opportunities for imaging in cardiovascular disease (CVD), according to Chiara Bucciarelli-Ducci, a consultant cardiologist at Royal Brompton & Harefield Hospitals in the UK, who spoke during an event organized by Bayer last March at ECR 2024.

‘Cancer is the big scary disease, but the first killer worldwide remains CVD,’ she said. ‘When we look at the numbers, where we want to make a difference and change patient outcome, that’s in CVD.’

Imaging, whether MR or CT, could really help in early detection, treatment and monitoring, and also in trying to predict what will happen to this patient. Imaging is also increasingly at the center of any cardiac intervention and drug development, she added.

Chiara Bucciarelli-Ducci from the Royal Brompton & Harefield Hospitals in the UK spoke during an event organized by Bayer last February in Vienna.

‘Bypass, angioplasty, changing valves… All of this is done under image guidance,’ she said. ‘Imaging is used in trials, because it will allow to do trials quicker with increased precision, and that means fewer costs, and also provide quicker results and quicker understanding of the mechanisms. That is why the field is growing.’

About 60M people worldwide have CVD and an estimated 17.9M die each year. More than four out of five deaths are due to heart attacks and strokes, and one out of three deaths occurs prematurely, in people younger than 70.

‘These statistics are alarming,’ she said. ‘The thing is that CVD is not just an elderly patient disease, it affects patients who are also quite young. Some people are born with congenital heart defects, and sudden cardiac death can occur in people in their 30s or 40s. So use of cardiovascular imaging spans a life time, that’s why it’s so relevant.’

Climbing down the ivory tower

Cardiac imaging has become crucial in the cardiologist’s daily practice. Ideally those tests need to be cheap, accessible, quick to deliver, so with rapid acquisition sequences and analysis, useful, i.e. providing actionable information, and accurate, according to Bucciarelli-Ducci, who is also CEO of the Society for Cardiovascular MRI.

‘It’s a very ambitious list, I know, but the bottleneck with imaging tests is how do we increase the adoption of these tools,’ she said. ‘With cardiac MR, we’re almost there. But we need not just be in our ivory tower. We need to really bring it to our patients to increase the value and the volumes of these tests.’

The clinical use of cardiac MR (CMR) is well documented in the literature, there are guidelines, but the tool has not been implemented to the extent it should be in clinical practice, she insisted.

Societies such as the European Society of Cardiology recommend CMR is the following indications: heart failure, cardiomyopathies, myocardial infarction with non-obstructive coronary arteries (MINOCA), chest pain and congenital heart disease, which together represent almost 90% of CVD.

CMR is particularly relevant in cardiomyopathies and chest pain, she explained. ‘Cardiac CT only allows to image the coronary arteries, whereas CMR is about anything else, meaning the heart as a muscle. When the heart does not work, CT doesn’t get that very much, but MRI does. MRI is like in vivo histology, it’s an opportunity to understand why the heart doesn’t work, whether there is inflammation, scar or fibrosis.’

Emerging applications for CMR are valvular heart disease, distinguishing atherosclerosis from cardiomyopathies, but also cardio oncology.

‘Cancer patients can die of toxicity because of cancer drugs, not cancer anymore,’ she said. ‘We need tools to measure that toxicity induced by drugs. CMR is good there too, because with it we can understand more about tissue. This is a huge field, as we understand more about the tissue of the heart.’

CMR examinations can now be performed in 20 minutes, thanks to faster protocols, and AI will reduce that time to just a few seconds. CMR is often the decisive test to finally diagnose patients who are challenging to diagnose. ‘It opens new scenarios for us and the rheumatologists and oncologists. Some of the referrals I get are from rheumatologists or oncologists.’

Top panel: patient with hypertrophic cardiomyopathy – inherited heart muscle disease
Mid panel: patient with myocarditis – inflammation of the heart
Bottom panel: patient with cardiac amyloidosis

Ischemia and no obstructive coronary artery (INOCA) disease is a new condition for cardiologists, who now have the tools to better understand patients, particularly women. ‘Women with chest pain with normal coronaries on CTCA were thought to have nothing,’ she said. ‘For years we thought the pain was caused by maybe menopause or hypochondria, but we’re learning that there is a kind of microvascular ischemia that needs more detailed imaging with PET and or stress CMR.’

Another interesting indication for CMR is cardio rheumatology, in which patients may have chest pain caused by inflammation of the heart. ‘We’ve been able to see fibrosis or inflammation in the past ten years, the field is really spanning’, she said.

Along with ECG, blood test and chest x-ray, CMR is now recommended in the initial evaluation of most patients with cardiovascular disease. ‘There is no doubt we should use it,’ she concluded, ‘but we must still address issues such as reimbursement, accessibility, efficiency through faster scanning and training.’