Cardiovascular magnetic resonance has been progressively elevated to a first-line diagnostic test across 13 ESC guidelines and 13 expert statements published between 2015 and 2025.
Over the last decade, ESC guidelines have repositioned cardiovascular magnetic resonance from a tool of last resort to a cornerstone of cardiovascular diagnostics.
AIMS: Cardiovascular magnetic resonance (CMR) has shifted from a problem-solving modality to a foundational, first-line test in European Society of Cardiology (ESC) guidance. This review synthesises how CMR is positioned within ESC guidelines (2015-2025) and allied EACVI/EHRA statements, emphasizing its decision-shaping role through accurate biventricular volumetry, tissue characterization (late gadolinium enhancement LGE, T1/T2 mapping, extracellular volume ECV), and flow quantification (phase-contract, with emerging 4D-flow). METHODS: We performed a structured narrative review of adult ESC clinical practice guidelines and allied expert statements (January 2015-December 2025) containing explicit CMR recommendations. Documents were identified via society portals and PubMed, excluding pediatric guidance and non-recommendation technical notes. Two independent reviewers extracted data on clinical context, CMR role, and recommendation Class/Level of Evidence, resolving discrepancies by consensus. RESULTS: The search identified 13 ESC guidelines-spanning coronary syndromes, sports cardiology, cardio-oncology, myocarditis, and valvular disease-and 13 supporting statements. The data demonstrate a progressive elevation of CMR to a strongly favored investigation (commonly Class I/IIa, Level B/C) in scenarios where precision imaging alters management. Allied expert statements standardize protocols, reference ranges, and quantification methods to facilitate consistent clinical implementation. CONCLUSION: ESC guidelines have repositioned CMR from a tool of last resort to a cornerstone of cardiovascular diagnostics. Its adjudicatory role leverages tissue characterization and quantification to resolve clinical scenarios with high diagnostic uncertainty, including MINOCA, suspected cardiomyopathy, sports participation after myocarditis, and complex valvular disease. Expert statements provide the practical framework for implementation, supporting the progressive integration of CMR into clinical pathways.
Gall et al. (Fri,) conducted a review in Cardiovascular disease. Cardiovascular magnetic resonance (CMR) was evaluated on Position and recommendation Class/Level of Evidence of CMR in ESC guidelines. Cardiovascular magnetic resonance has been progressively elevated to a first-line diagnostic test across 13 ESC guidelines and 13 expert statements published between 2015 and 2025.