Skip to main content
  • Research article
  • Open access
  • Published:

Does stress perfusion imaging improve the diagnostic accuracy of late gadolinium enhanced cardiac magnetic resonance for establishing the etiology of heart failure?

A Correction to this article was published on 21 January 2019

This article has been updated



Late gadolinium enhanced cardiovascular magnetic resonance (LGE-CMR) has excellent specificity, sensitivity and diagnostic accuracy for differentiating between ischemic cardiomyopathy (ICM) and non-ischemic dilated cardiomyopathy (NICM). CMR first-pass myocardial perfusion imaging (perfusion-CMR) may also play role in distinguishing heart failure of ischemic and non-ischemic origins, although the utility of additional of stress perfusion imaging in such patients is unclear. The aim of this retrospective study was to assess whether the addition of adenosine stress perfusion imaging to LGE-CMR is of incremental value for differentiating ICM and NICM in patients with severe left ventricular systolic dysfunction (LVSD) of uncertain etiology.


We retrospectively identified 100 consecutive adult patients (median age 69 years (IQR 59–73)) with severe LVSD (mean LV EF 26.6 ± 7.0%) referred for perfusion-CMR to establish the underlying etiology of heart failure. The cause of heart failure was first determined on examination of CMR cine and LGE images in isolation. Subsequent examination of complete adenosine stress perfusion-CMR studies (cine, LGE and perfusion images) was performed to identify whether this altered the initial diagnosis.


On LGE-CMR, 38 patients were diagnosed with ICM, 46 with NICM and 16 with dual pathology. With perfusion-CMR, there were 39 ICM, 44 NICM and 17 dual pathology diagnoses. There was excellent agreement in diagnoses between LGE-CMR and perfusion-CMR (κ 0.968, p<0.001). The addition of adenosine stress perfusion images to LGE-CMR altered the diagnosis in only two of the 100 patients.


The addition of adenosine stress perfusion-CMR to cine and LGE-CMR provides minimal incremental diagnostic yield for determining the etiology of heart failure in patients with severe LVSD.

Peer Review reports


Identifying the etiology of heart failure has important management and prognostic implications [1]. Therapeutic strategies for ischemic cardiomyopathy (ICM) include revascularisation and/or secondary prevention measures such as antiplatelet and lipid lowering therapies. Conversely, the management of non-ischemic dilated cardiomyopathy (NICM) relies predominantly on pharmacological agents and device therapy [2]. Rarer causes of NICM (e.g. sarcoid, amyloid, HIV) require treatment of the underlying condition [3]. Importantly survival rates are poorer in those patients with heart failure of ischemic origin [4]. Clinical guidelines suggest echocardiography as the initial investigation of choice for evaluation of chronic heart failure [1, 5]. In many instances, echocardiography may reliably establish the underlying cause of heart failure. Myocardial regional wall motion abnormalities alone, however, may not distinguish heart failure of ischemic origin from NICM, since segmental wall motion abnormalities may accompany both [6]. Where echocardiography does not clearly identify the etiology of chronic heart failure, cardiac magnetic resonance imaging (CMR) is advantageous [1], owing to its capacity to detect evidence of myocardial infarction and non-ischemic fibrosis and assess ischemia and viability in a single examination [7].

Late gadolinium enhanced CMR (LGE-CMR) has been shown to be non-inferior (and indeed may be superior) to coronary angiography in differentiating heart failure due to coronary artery disease (CAD) from NICM [8, 9]. Subendocardial LGE is present in CAD, whereas patients with NICM have either no LGE or mid-wall late enhancement that does not correspond to a coronary artery territory (Fig. 1) [9]. Patients with heart failure and a history of ischemic heart disease have a high prevalence of LGE visible on CMR (88% in one report) [10]. This suggests a high likelihood that LGE-CMR will yield a diagnosis of ICM by hyperenhancement patterns alone, without the need for additional perfusion imaging. Following myocardial infarction, the presence of LGE affecting ≤50% of the thickness of the myocardium predicts the likelihood of functional recovery in response to revascularisation of the affected coronary territory [11, 12]. In NICM, the presence of mid-wall fibrosis is also of prognostic value, being an independent predictor of cardiovascular and all-cause mortality [13].

Fig. 1
figure 1

Illustration of typical patterns of LGE seen in NICM and ICM. White areas within the myocardium represent LGE. a Mid-wall LGE is commonly seen in NICM, whereas b a subendocardial distribution of LGE is typical in ICM

CMR first-pass myocardial perfusion imaging (perfusion-CMR) has been shown in several large studies to have excellent sensitivity and specificity for detection of CAD and may thus play a role in distinguishing heart failure of ischemic and non-ischemic origins [14, 15]. However, the added value of adenosine stress perfusion-CMR in subjects with severe left ventricular systolic dysfunction (LVSD) has not been investigated previously. Given that LGE-CMR alone has excellent specificity (96%), sensitivity (100%) and diagnostic accuracy (95%) for differentiating between ICM and NICM [8], the utility of additional of stress perfusion imaging in such patients is questionable.

Adenosine stress perfusion-CMR imaging adds time (approximately 15 min added time for the perfusion-CMR protocol) and expense to the CMR protocol, due to the need for additional electrocardiograms, adenosine preparations, infusion pumps and lines, as well as physician-supervision. Undesirable symptoms and potentially serious complications may occur with adenosine infusion, albeit infrequently [1619]. These include wheeze secondary to bronchospasm, Mobitz II 2nd or 3rd degree atrioventricular block, and angina requiring sublingual nitrates [17]. Furthermore, in patients with heart failure, there is impairment of adenosine receptor expression and signal-transduction [20], which may diminish the hemodynamic response for stress perfusion assessment, compromising diagnostic confidence.

In our regional cardiac centre, over 1000 clinical perfusion-CMR studies are performed annually. Approximately 10% of these are to identify the cause of heart failure, and despite a lack of evidence of additional benefit, stress perfusion is usually requested and performed.

The aim of this retrospective study was to assess whether the addition of adenosine stress perfusion imaging to LGE-CMR is of incremental value for differentiating ICM and NICM in patients with severe LVSD of uncertain etiology.


Study population

We retrospectively identified 100 consecutive adult patients with severe LVSD on echocardiography, referred for perfusion-CMR to ascertain the underlying etiology of heart failure. Patients were scanned between April 2015 and March 2016. Severe LVSD was defined as a left ventricular ejection fraction (LV EF) ≤35% and was confirmed by CMR volumetric and functional analysis prior to inclusion in the study. Participants’ past medical history, medications, electrocardiographic data, resting pulse and blood pressure were recorded at the time of the CMR.

The study was approved as a clinical audit and ethics approval was deemed unnecessary.

CMR image acquisition

Clinical perfusion-CMR studies were undertaken on either a 1.5 T (Siemens Avanto, Erlangen, Germany) or 3 T scanner (Siemens Skyra, Erlangen, Germany). Cardiac volumes and function were performed using standard CMR techniques as previously described by our group [21]. For stress perfusion, adenosine (140mcg/kg/min, increased up to a maximum of 210mcg/kg/min to achieve a satisfactory haemodynamic stress response) [18] was infused for 3–5 min. Patients underwent pulse, blood pressure and pulse oximetry monitoring at baseline and at 1-min intervals during adenosine infusion. Symptomatic response to adenosine was documented. During peak stress a bolus of gadolinium-based contrast (Gadoterate meglumine, Dotarem, Guerbet LLC, France) was injected (0.1 mmol/kg at 1.5 T and 0.075 mmol/kg at 3 T), followed by a 20 mL bolus of normal saline, at a rate of 5 mL/s and perfusion images were acquired using a saturation recovery gradient echo pulse sequence. Adenosine infusion was then discontinued and a complete short axis cine stack was performed before rest perfusion images were acquired following administration of a second bolus of gadolinium-based contrast agent (total dose 0.15 mmol/kg). LGE images in 3 long axis views and a complete short axis stack were acquired after a further delay of 5–10 min.

CMR image analysis

Scans were anonymized and sent to a separate workstation for analysis which was performed blinded to all patient details, by two specialists in CMR (JRA and JK) as recommended by expert consensus [22]. No clinical information was made available prior to or during image analysis. Definitions for etiology of severe LVSD were pre-defined as “ischemic”, “non-ischemic” or “dual-pathology” (having both ischemic and non-ischemic components and where the extent of infarction and/or ischemia did not explain the degree of LVSD). Image quality was rated as “good”, “moderate”, “poor” or “not-analyzable” for each modality. A two-stage process was employed for image analysis. The etiology of severe LVSD was determined first determined by consensus between JRA and JK after examination of cine and LGE images. Following this, the perfusion sequences were interpreted with the cine and LGE images and it was recorded whether the etiology of LVSD changed depending on the presence of reversible perfusion defects.

Invasive coronary angiography

Coronary angiograms were examined in those patients in the cohort who underwent angiography on clinical grounds. Images were analyzed blinded to patient details and CMR image interpretation results by an experienced cardiologist (GPM). Coronary artery disease was pre-defined as being present if a coronary artery stenosis of ≥50% the luminal diameter of the artery was observed and was noted as severe if stenosis severity was >70%.

Statistical analyses

Normality was assessed using Kolmogorov-Smirnov tests, histograms, and Q-Q plots. Continuous data were expressed as mean ± standard deviation, if normally distributed. Non-parametric variables were expressed as median and interquartile range. One-way analysis of variance (ANOVA) was used to compare normal data and the Independent-Samples Kruskal-Wallis test for non-normal data between groups. The Kappa statistic was used as a measure of agreement between the components of the CMR scans with and without stress perfusion. Statistical analysis was undertaken using SPSS version 20.0 software.


Baseline characteristics

The study group consisted of 100 patients referred for clinical stress perfusion-CMR to investigate the etiology of severe LVSD. Demographic characteristics and CMR volumetric and functional data are shown in Table 1. The mean LV EF of the cohort was 26.6 ± 7.0% and there were no significant differences in LV function or volumes between patients with a diagnosis of ICM, NICM or dual pathology (Table 1).

Table 1 Baseline characteristics of the 100 study participants

Etiology of LVSD by combined cine plus LGE-CMR

Image quality was excellent or good in 98 and poor in 2 studies. Thirty-eight patients were classified as having ischemic, 46 non-ischemic and 16 dual pathology as the cause of LVSD (Table 2). Fifty-three patients had subendocardial or transmural hyperenhancement consistent with previous myocardial infarction. Forty-nine (80%) patients with NICM or dual pathology had evidence of mid-wall hyperenhancement on LGE-CMR; the other 13 had no visible LGE. The vast majority (n = 15, 94%) of patients with dual pathology had a combination of hyperenhancement patterns (subendocardial/transmural and mid-wall).

Table 2 Cause of LVSD diagnosed by LGE-CMR and perfusion-CMR

Etiology of LVSD by complete stress perfusion-CMR studies

Image quality for first-pass perfusion was rated as good or excellent in 99 and poor in 1 patient. There were reversible perfusion defects in 23/54 (43%) patients with infarction and in 1 patient with no LGE. There was excellent agreement in diagnoses between LGE-CMR and perfusion-CMR (κ 0.968, p=<0.001) (Table 2), yielding a change in diagnosis from LGE-CMR in only 2 cases. In the first of these (78-year-old male, LV EF 26%), the LGE-CMR diagnosis was NICM. There was global LV hypokinesis with basal inferoseptal mid-wall LGE (Fig. 2a). The perfusion-CMR diagnosis was dual pathology as an inferolateral subendocardial perfusion abnormality was visualised, suggestive of ischemia (Fig. 2b), but not severe enough to account for the degree of LV impairment observed. In the second case (a 77-year-old female), the LGE-CMR diagnosis was NICM: image quality for LGE imaging was rated as poor (though still considered diagnostic), and no enhancement was visualised (Fig. 3a). The diagnosis by perfusion-CMR was ICM with demonstration of a subendocardial basal and mid LV anteroseptal perfusion defect (Fig. 3b). Subsequently coronary angiography revealed a significant LAD stenosis (Fig. 3c) and the patient underwent revascularisation.

Fig. 2
figure 2

a Two-chamber LGE image with inferior LV mid-wall hyperenhancement (arrow). b First-pass perfusion-CMR image demonstrating an inferolateral subendocardial perfusion abnormality (arrow)

Fig. 3
figure 3

a Mid short-axis LGE window; there is no hyperenhancement to suggest myocardial infarction. b First-pass perfusion-CMR image showing a mid LV anteroseptal reversible perfusion defect (arrow). c The corresponding coronary angiogram image; there is a chronic total occlusion of the proximal-mid left anterior descending artery (arrow)

Angiographic findings

Thirty-two of the patients underwent coronary angiography after CMR. The vast majority (n = 30, 93.8%) of these showed significant CAD. Both patients who underwent angiography that did not reveal significant CAD had LGE-CMR and perfusion-CMR diagnoses of NICM. LGE-CMR had a sensitivity of 87% for predicting significant CAD in subjects with severe LVSD, identifying ICM or dual pathology in 26/30 patients with significant CAD on angiography. Sensitivity of perfusion-CMR for predicting significant CAD was 90% (27/30 patients with significant CAD identified as having ICM or dual pathology). Only three cases of CAD identified by angiography were not detected by either LGE-CMR or perfusion-CMR (Table 3). In two of these, the degree of coronary disease was not deemed severe enough to alone account for the degree of LV impairment.

Table 3 Summary of angiographic and CMR findings in patients with angiographically-determined significant CAD and a diagnosis of NICM on CMR


This study is the first to evaluate the incremental value of perfusion-CMR over LGE-CMR in identifying the etiology of heart failure in patients with severe LVSD. We have shown that the vast majority of patients with LVSD are identified by LGE and that the addition of stress perfusion only identified one additional patient with important ischemia requiring revascularisation.

LGE-CMR versus perfusion-CMR

LGE-CMR is a proven technique for determining the etiology of heart failure [9], having been shown in previous studies to accurately differentiate between ICM and NICM [23, 24]. Clinical guidelines advocate the use of LGE-CMR in heart failure, when echocardiography is non-diagnostic [1, 25]. The utilisation of LGE-CMR in this context is known to have significant clinical impact; influencing patient management, clinical decisions and diagnoses in 65% of patients in one study [26]. When mid-wall LGE is present in NICM, this portends a poorer prognosis [13]. A high proportion of our patients with NICM had mid-wall LGE in comparison to the published literature (80 versus 30% in Gulati et al.) [13]. This is probably the result of our study group being older (69 (59–73) versus 51 ± 15 years) and with much poorer LV systolic function (mean LV EF 27.5 ± 6.8% versus 37.2 ± 13.1%) [13].

Perfusion-CMR is highly accurate for identifying myocardial ischemia due to CAD [15, 27, 28]. No published data exist, however, characterising the role of perfusion-CMR in determining the etiology of severe LVSD. Despite this, it is routine in our institution to undertake full adenosine stress perfusion-CMR studies for identifying the cause of heart failure in patients with newly diagnosed severe LVSD. The EuroCMR registry, which includes data on more than 27,000 consecutive CMR studies from over 15 European countries, showed that almost a third (29.3%) of CMR studies include adenosine stress perfusion imaging [16]. Data on the specific indications for perfusion-CMR are not presented in the EuroCMR registry, but it is likely that a significant number of these studies were also performed in subjects with severe LVSD.

Adenosine stress perfusion imaging adds time and expense to the CMR protocol. Seventy five to 100% of all complications associated with CMR occur due to administration of pharmacologic stress agents [16]. There is also evidence to suggest that patients with heart failure exhibit a diminished response to adenosine due to down regulation of adenosine receptors in the failing myocardium [16]. Clearly the role of perfusion-CMR in determining the etiology of heart failure should be subject to scrutiny before routine implementation in clinical practice.

We found excellent agreement between the causes of LVSD diagnosed by LGE-CMR and by perfusion-CMR, suggesting that perfusion-CMR is of limited additional benefit over LGE-CMR for the specific indication of identifying the etiology of heart failure. In only two of our 100 patients did perfusion-CMR alter the diagnosis established by LGE-CMR (and led to a meaningful change in patient management, i.e. revascularisation, in only one patient). Perfusion-CMR did, however, identify reversible ischemia in 43% of patients with a non-stress-CMR diagnosis of ICM/dual pathology. Whilst this did not alter the diagnosis in these patients it may have implications on clinical management. Generally both LGE-CMR and perfusion-CMR had excellent sensitivity for detection of CAD. Importantly these analyses were made entirely blinded to patient details and medical history, which in clinical practice would ordinarily guide risk stratification and decision-making and raise suspicion of CAD.

Clinical implications

Our study demonstrates that stress perfusion-CMR is of minimal incremental benefit in diagnosing the cause of severe LVSD. It is therefore contentious whether stress testing should be routinely performed in this context. Patients with severe LVSD attributed to previous infarction on LGE-CMR with a likelihood of functional recovery often undergo coronary angiography and revascularisation. However the role of revascularization in patients with ICM in the absence of symptoms is controversial. In the STITCH trial, there was no significant difference in outcomes when patients with heart failure and coronary artery disease underwent surgical revascularization versus medical therapy alone [29]. In such instances perfusion-CMR is therefore of limited added benefit. In cases of severe LVSD where LGE-CMR excludes ICM by patterns of hyperenhancement specific to NICM, exposing the patient to risks of invasive angiography could be unwarranted as the likelihood of identifying significant coronary disease is low. On the other hand, we found that perfusion-CMR identified additional ischemia in half our patients diagnosed with ICM. In these cases, perfusion-CMR may influence subsequent management, although the benefit of routine revascularisation in the absence of angina over medical management is far from clear [29].

The present study challenges the incremental role of perfusion-CMR over LGE-CMR for diagnosing the etiology of heart failure in severe LVSD. Clinical guidelines do not specifically recommend perfusion-CMR for this purpose [1, 5]. However, observations from our own clinical practice and EuroCMR registry data suggest that perfusion-CMR is routinely utilised to determine the cause of severe LVSD when echocardiography is non-diagnostic [16]. Exposing patients in these cases to the added risks of adenosine infusion, together with increasing MR scanning times and expense are probably unjustified at present.


The retrospective and single-centre design limits the strength of this study, as does the relatively small sample size. Coronary angiography, as the reference standard for CAD, was not performed on all subjects in the cohort to exclude CAD. Computed tomography coronary angiography can be used to reliably exclude the presence of CAD but will be difficult to interpret in high risk patients with coronary calcium and does not provide prognostic information related to LGE [30].


Adenosine stress perfusion-CMR is of minimal additional benefit to cine and LGE-CMR for determining the etiology of heart failure in patients with severe LVSD. Prospective studies are required to define the role of perfusion-CMR in heart failure and identify those patients most likely to benefit from the addition of perfusion imaging to LGE-CMR.

Change history

  • 21 January 2019

    Following publication of the original article [1], the author reported his name has erroneously spelled as Abishek Shetye. The correct name is Abhishek Shetye.



Coronary artery disease


Cardiac magnetic resonance


Ischemic cardiomyopathy


Late gadolinium enhancement


Left ventricular ejection fraction


Left ventricular systolic dysfunction


Non-ischemic cardiomyopathy


  1. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016.

  2. Wu AH. Management of patients with non-ischaemic cardiomyopathy. Heart. 2007;93(3):403–8.

    Article  Google Scholar 

  3. Cerrato E, D'Ascenzo F, Biondi-Zoccai G, Calcagno A, Frea S, Grosso Marra W, et al. Cardiac dysfunction in pauci symptomatic human immunodeficiency virus patients: a meta-analysis in the highly active antiretroviral therapy era. Eur Heart J. 2013;34(19):1432–6.

    Article  CAS  Google Scholar 

  4. Bart BA, Shaw LK, McCants Jr CB, Fortin DF, Lee KL, Califf RM, et al. Clinical determinants of mortality in patients with angiographically diagnosed ischemic or nonischemic cardiomyopathy. J Am Coll Cardiol. 1997;30(4):1002–8.

    Article  CAS  Google Scholar 

  5. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey Jr DE, Drazner MH, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. Circulation. 2013;128(16):1810–52.

    Article  Google Scholar 

  6. Wallis DE, O'Connell JB, Henkin RE, Costanzo-Nordin MR, Scanlon PJ. Segmental wall motion abnormalities in dilated cardiomyopathy: a common finding and good prognostic sign. J Am Coll Cardiol. 1984;4(4):674–9.

    Article  CAS  Google Scholar 

  7. Karamitsos TD, Neubauer S. Cardiovascular magnetic resonance in heart failure. Curr Cardiol Rep. 2011;13(3):210–9.

    Article  Google Scholar 

  8. Assomull RG, Shakespeare C, Kalra PR, Lloyd G, Gulati A, Strange J, et al. Role of cardiovascular magnetic resonance as a gatekeeper to invasive coronary angiography in patients presenting with heart failure of unknown etiology. Circulation. 2011;124(12):1351–60.

    Article  Google Scholar 

  9. McCrohon JA, Moon JC, Prasad SK, McKenna WJ, Lorenz CH, Coats AJ, et al. Differentiation of heart failure related to dilated cardiomyopathy and coronary artery disease using gadolinium-enhanced cardiovascular magnetic resonance. Circulation. 2003;108(1):54–9.

    Article  CAS  Google Scholar 

  10. Bourantas CV, Nikitin NP, Loh HP, Lukaschuk EI, Sherwi N, de Silva R, et al. Prevalence of scarred and dysfunctional myocardium in patients with heart failure of ischaemic origin: a cardiovascular magnetic resonance study. J Cardiovasc Magn Reson. 2011;13:53.

    Article  Google Scholar 

  11. Kim RJ, Wu E, Rafael A, Chen EL, Parker MA, Simonetti O, et al. The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction. N Engl J Med. 2000;343(20):1445–53.

    Article  CAS  Google Scholar 

  12. Selvanayagam JB, Kardos A, Francis JM, Wiesmann F, Petersen SE, Taggart DP, et al. Value of delayed-enhancement cardiovascular magnetic resonance imaging in predicting myocardial viability after surgical revascularization. Circulation. 2004;110(12):1535–41.

    Article  Google Scholar 

  13. Gulati A, Jabbour A, Ismail TF, Guha K, Khwaja J, Raza S, et al. Association of fibrosis with mortality and sudden cardiac death in patients with nonischemic dilated cardiomyopathy. JAMA. 2013;309(9):896–908.

    Article  CAS  Google Scholar 

  14. Greenwood JP, Motwani M, Maredia N, Brown JM, Everett CC, Nixon J, et al. Comparison of cardiovascular magnetic resonance and single-photon emission computed tomography in women with suspected coronary artery disease from the clinical evaluation of magnetic resonance imaging in coronary heart disease (CE-MARC) trial. Circulation. 2014;129(10):1129–38.

    Article  Google Scholar 

  15. Schwitter J, Wacker CM, van Rossum AC, Lombardi M, Al-Saadi N, Ahlstrom H, et al. MR-IMPACT: comparison of perfusion-cardiac magnetic resonance with single-photon emission computed tomography for the detection of coronary artery disease in a multicentre, multivendor, randomized trial. Eur Heart J. 2008;29(4):480–9.

    Article  Google Scholar 

  16. Bruder O, Wagner A, Lombardi M, Schwitter J, van Rossum A, Pilz G, et al. European cardiovascular magnetic resonance (EuroCMR) registry--multi national results from 57 centers in 15 countries. J Cardiovasc Magn Reson. 2013;15:9.

    Article  Google Scholar 

  17. Karamitsos TD, Arnold JR, Pegg TJ, Cheng AS, van Gaal WJ, Francis JM, et al. Tolerance and safety of adenosine stress perfusion cardiovascular magnetic resonance imaging in patients with severe coronary artery disease. Int J Cardiovasc Imaging. 2009;25(3):277–83.

    Article  Google Scholar 

  18. Karamitsos TD, Ntusi NA, Francis JM, Holloway CJ, Myerson SG, Neubauer S. Feasibility and safety of high-dose adenosine perfusion cardiovascular magnetic resonance. J Cardiovasc Magn Reson. 2010;12:66.

    Article  Google Scholar 

  19. Khoo JP, Grundy BJ, Steadman CD, Sonnex EP, Coulden RA, McCann GP. Stress cardiovascular MR in routine clinical practice: referral patterns, accuracy, tolerance, safety and incidental findings. Br J Radiol. 2012;85(1018):e851–7.

    Article  CAS  Google Scholar 

  20. Asakura M, Asanuma H, Kim J, Liao Y, Nakamaru K, Fujita M, et al. Impact of adenosine receptor signaling and metabolism on pathophysiology in patients with chronic heart failure. Hypertens Res. 2007;30(9):781–7.

    Article  CAS  Google Scholar 

  21. Steadman CD, Jerosch-Herold M, Grundy B, Rafelt S, Ng LL, Squire IB, et al. Determinants and functional significance of myocardial perfusion reserve in severe aortic stenosis. JACC Cardiovasc Imaging. 2012;5(2):182–9.

    Article  Google Scholar 

  22. Schulz-Menger J, Bluemke DA, Bremerich J, Flamm SD, Fogel MA, Friedrich MG, et al. Standardized image interpretation and post processing in cardiovascular magnetic resonance: Society for Cardiovascular Magnetic Resonance (SCMR) board of trustees task force on standardized post processing. J Cardiovasc Magn Reson. 2013;15:35.

    Article  Google Scholar 

  23. Casolo G, Minneci S, Manta R, Sulla A, Del Meglio J, Rega L, et al. Identification of the ischemic etiology of heart failure by cardiovascular magnetic resonance imaging: diagnostic accuracy of late gadolinium enhancement. Am Heart J. 2006;151(1):101–8.

    Article  Google Scholar 

  24. Soriano CJ, Ridocci F, Estornell J, Jimenez J, Martinez V, De Velasco JA. Noninvasive diagnosis of coronary artery disease in patients with heart failure and systolic dysfunction of uncertain etiology, using late gadolinium-enhanced cardiovascular magnetic resonance. J Am Coll Cardiol. 2005;45(5):743–8.

    Article  Google Scholar 

  25. NICE. Chronic heart failure: management of chronic heart failure in adults in primary and secondary care. 2010.

    Google Scholar 

  26. Abbasi SA, Ertel A, Shah RV, Dandekar V, Chung J, Bhat G, et al. Impact of cardiovascular magnetic resonance on management and clinical decision-making in heart failure patients. J Cardiovasc Magn Reson. 2013;15:89.

    Article  Google Scholar 

  27. Greenwood JP, Maredia N, Younger JF, Brown JM, Nixon J, Everett CC, et al. Cardiovascular magnetic resonance and single-photon emission computed tomography for diagnosis of coronary heart disease (CE-MARC): a prospective trial. Lancet. 2012;379(9814):453–60.

    Article  Google Scholar 

  28. Nandalur KR, Dwamena BA, Choudhri AF, Nandalur MR, Carlos RC. Diagnostic performance of stress cardiac magnetic resonance imaging in the detection of coronary artery disease: a meta-analysis. J Am Coll Cardiol. 2007;50(14):1343–53.

    Article  Google Scholar 

  29. Velazquez EJ, Lee KL, Jones RH, Al-Khalidi HR, Hill JA, Panza JA, et al. Coronary-artery bypass surgery in patients with ischemic Cardiomyopathy. N Engl J Med. 2016;374(16):1511–20.

    Article  CAS  Google Scholar 

  30. Vavere AL, Arbab-Zadeh A, Rochitte CE, Dewey M, Niinuma H, Gottlieb I, et al. Coronary artery stenoses: accuracy of 64-detector row CT angiography in segments with mild, moderate, or severe calcification--a subanalysis of the CORE-64 trial. Radiology. 2011;261(1):100–8.

    Article  Google Scholar 

Download references





Availability of data and materials

The datasets during and/or analyzed during the current study available from the corresponding author on reasonable request.

Authors’ contributions

GSG, GPM, JRA and IS conceived the idea for the study and developed the initial protocol. GSG, AS, EL and DJS developed study documents, retrospectively identified patients and managed the study. JRA and JK performed the CMR analyses. GPM performed the coronary angiography analysis. GSG and FL performed statistical analysis. GSG wrote the paper, which all authors critically reviewed. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Ethics approval and consent to participate

This study was approved as an audit by our institution’s clinical audit board and ethical approval was deemed unnecessary.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Gaurav S. Gulsin.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gulsin, G.S., Shetye, A., Khoo, J. et al. Does stress perfusion imaging improve the diagnostic accuracy of late gadolinium enhanced cardiac magnetic resonance for establishing the etiology of heart failure?. BMC Cardiovasc Disord 17, 98 (2017).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: