Key result
CMR-first strategy proves ~20% less sufficient than CATH for diagnosing ICM but reduces invasive procedures.
Why the study?
Percutaneous invasive coronary angiography remains preferred to diagnose ischemic cardiomyopathy in new-onset HFrEF, but whether CMR could diagnose it as effectively and reduce invasive procedures was unknown.
Does a CMR-first strategy diagnose ischemic cardiomyopathy as effectively as a CATH-first strategy and reduce invasive procedures in adults with new-onset HFrEF?
RCT (n=229)
Blinded
Randomized
Yes
Does a CMR-first strategy diagnose ischemic cardiomyopathy as effectively as a CATH-first strategy and reduce invasive procedures in adults with new-onset HFrEF?
Absolute Event Rate: 80% vs 100%
p-value: p=<0.001
In patients with new-onset HFrEF, a CMR-first diagnostic strategy offers similar sensitivity but lower specificity compared to invasive angiography for diagnosing ischemic cardiomyopathy, while potentially reducing the need for invasive procedures by nearly half.
CMR-first strategy is not sufficient for ischemic cardiomyopathy diagnosis; challenges full replacement of catheterization while supporting reduced procedures in new-onset HFrEF.
BACKGROUND: New-onset heart failure with reduced ejection fraction (HFrEF) requires further diagnostic evaluation to determine its underlying cause. Despite the potential of cardiac magnetic resonance (CMR) imaging to identify ischemic and nonischemic causes, percutaneous invasive coronary angiography (CATH) remains the preferred tool for diagnosing ischemic cardiomyopathy (ICM). OBJECTIVES: This study aimed to determine whether a CMR-first strategy could diagnose ICM as effectively as CATH (primary endpoint) and potentially reduce the number of invasive procedures (secondary endpoint). METHODS: In this multicenter 2-armed diagnostic trial (Magnetic Resonance Imaging vs Invasive Coronary Angiography as First-Line Diagnostic Modality in New-Onset Heart Failure), 229 adults with new-onset HFrEF were randomized to undergo CMR or CATH first and the other modality second. Separate expert panels evaluated both modalities, blinded to each other's results. The cardiologist-in-charge was blinded to the panel results and served as the reference standard. RESULTS: A total of 203 patients (mean age: 62 ± 14 years, 28% women) had evaluable pairs of diagnostic modalities (108 CATH-first). For diagnosing ICM, the panels considered CATH to be sufficient in 100% (105/105) and CMR in 80% (76/95; P < 0.001). Compared with the reference, sensitivity for diagnosing ICM was high for both (CATH 91%, CMR 90%; P = 1.00), but CMR had lower specificity (98% vs 74%; P < 0.001). According to the CMR panel, 48% (46/95) of CATH procedures could have been avoided with a CMR-first strategy, dropping to 45% when excluding patients who underwent coronary interventions. CONCLUSIONS: Although CATH was superior for diagnosing ICM, CMR showed similar sensitivity and could significantly reduce CATH procedures without increasing the risk of missing critical coronary interventions. Longitudinal studies are needed to assess whether a CMR-first strategy confers prognostic benefit. (Magnetic Resonance Imaging vs Invasive Coronary Angiography as First-Line Diagnostic Modality in New-Onset Heart Failure; ISRCTN16515058).
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Güder et al. (2025) conducted an RCT in New-onset heart failure with reduced ejection fraction (HFrEF) (n=229). Cardiac magnetic resonance (CMR) imaging first vs. Percutaneous invasive coronary angiography (CATH) first was evaluated on Sufficient for diagnosing ischemic cardiomyopathy (ICM) (p=<0.001). A CMR-first strategy was less sufficient than CATH for diagnosing ischemic cardiomyopathy (80% vs 100%; P<0.001), but showed similar sensitivity (90% vs 91%) and could reduce invasive procedures.
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