Cardiac MRI: LGE patterns and clinical questions

ESC 2023 says CMR is particularly useful if echocardiography provides poor image quality.^[1] This page covers the sequences, the LGE patterns, tissue mapping, the Lake Louise criteria, MINOCA, amyloid, HCM risk, ischaemia, viability and device safety, each as the named guideline states it. Disease management lives in Hypertrophic cardiomyopathy, Cardiac amyloidosis: AL vs ATTR, imaging, tafamidis, Acute pericarditis: diagnosis and colchicine, Chronic coronary syndromes: pre-test likelihood, the CCTA pathway and treatment and ICD and CRT indications in heart failure.

What CMR measures

ESC 2026 HF calls CMR the gold standard for assessing LV volumes and mass, owing to its high spatial resolution and reproducibility.^[3] ESC 2023 adds tissue characterisation, which it calls particularly important in non-dilated LV cardiomyopathy (NDLVC), ARVC, myocarditis, amyloidosis, sarcoidosis and other inflammatory disease, and iron overload or haemochromatosis.^[1]

The core protocol

ESC 2023 says initial CMR evaluation in cardiomyopathy should routinely include cine imaging sequences, T2-weighted sequences, pre- and post-contrast T1 mapping, and late gadolinium enhancement (LGE).^[1] When haemochromatosis is suspected, T2* mapping should be employed.^[1] ESC 2023 says the findings should be assessed collectively with genetic results and other clinical features by experienced operators.^[1]

Sequences and what they show

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ESC 2025 names the diagnostic targets of non-ischaemic myocardial inflammation as oedema, hyperaemia and capillary leak, and necrosis/fibrosis.^[2] It adds that imaging evidence of myocardial inflammation does not provide the underlying histotype.^[2]

Reading the LGE pattern

ESC 2024 CCS says LGE CMR can reveal a typical pattern of scarred myocardium in patients who have already had an MI.^[4] ESC 2025 says non-ischaemic patterns of LGE do not typically follow a coronary artery distribution.^[2] ESC 2026 HF calls LGE useful in distinguishing ischaemic from non-ischaemic aetiology as well as certain cardiomyopathies.^[3]

LGE and tissue patterns named in the ESC 2023 and ESC 2025 guidelines (selected)

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ESC 2023 says CMR rarely distinguishes the causes of HCM by their magnetic properties alone, though the distribution and severity of interstitial expansion can, in context, suggest specific diagnoses.^[1] ESC 2025 says that on CMR, cardiac sarcoidosis has a wide range of potential findings and is often considered the "great mimicker" of various cardiac conditions.^[2]

In DCM, ESC 2023 says CMR can show myocardial oedema, which may suggest a myocarditic or inflammatory cause, and LGE, whose distribution may allow exclusion of myocardial infarction.^[1] It says LGE distribution and extent hold prognostic value both for arrhythmia and heart failure severity.^[1] In NDLVC, CMR with LGE is the foremost imaging modality because it confirms the non-ischaemic myocardial fibrosis that is essential for the diagnosis in most cases (ESC 2023).^[1]

For ARVC, ESC 2023 says CMR should be considered the first-line test for the RV functional and structural abnormalities criterion, as it has demonstrated superior sensitivity.^[1] It adds that contrast-enhanced CMR is the only tool allowing the detection of LV involvement, which remains otherwise underestimated by the 2010 Task Force Criteria.^[1]

When CMR is indicated: the formal rows

ESC 2023 Recommendation Table 5 is the general cardiomyopathy row set; it has five rows, all given below.^[1] ESC 2023 also says serial follow-up CMR, every 2–5 years depending on initial severity and clinical course, can assist in evaluating progression and the benefits of therapy.^[1]

ESC 2023 Recommendation Table 5: CMR in patients with cardiomyopathy

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Other indication rows by body and year

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ESC 2026 HF Table 6 lists three ESC 2021 HF CMR rows as revised in the 2026 version into the single contrast-enhanced CMR row above.^[3] The 2021 rows covered structure and function with poor acoustic windows; tissue characterisation in suspected infiltrative disease, Fabry disease, inflammatory disease (myocarditis), LV non-compaction, amyloid, sarcoidosis and iron overload/haemochromatosis; and LGE in DCM to distinguish ischaemic from non-ischaemic myocardial damage.^[3] They are history, so no mark here rests on them.^[3]

ESC 2022 VA adds that in a patient with frequent PVCs, LGE suggests structural heart disease with frequent PVCs rather than PVC-induced cardiomyopathy, in which LGE is mostly absent.^[6] ESC 2026 HF says abnormal cardiac conduction as the sole cause of HFrEF is most likely with LBBB, a wide QRS and no myocardial scarring on CMR, and in RV pacing-induced HF.^[3]

Myocarditis and the updated Lake Louise criteria

ESC 2025 says non-ischaemic myocardial inflammation can be diagnosed by CMR according to the updated Lake Louise criteria (LLC).^[2] The diagnosis rests on at least one T2-based criterion plus ideally one T1-based criterion.^[2] Having both increases specificity for diagnosing acute myocarditis, but possible myocarditis can still be diagnosed on one criterion in an appropriate clinical scenario, although with less specificity.^[2]

• Supportive criteria (ESC 2025): pericardial abnormalities, which suggest concomitant pericarditis, and global or regional LV systolic dysfunction on cine imaging.^[2]
• Pericardial effusion (ESC 2025 Figure 4 legend): its presence suggests concomitant pericarditis.^[2]
• Mapping (ESC 2025): the updated LLC, which include parametric mapping methods (T1/T2/ECV), should be applied for diagnosis, as the combined approach increases the diagnostic accuracy.^[2]
• Timing (ESC 2025): the diagnostic accuracy of CMR is higher if performed early in the disease (best within the first 2 weeks).^[2]

CMR categories in the ESC 2025 inflammatory myopericardial syndrome criteria (Table 4 footnote)

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In ESC 2025 Table 4, myocardial oedema and/or LGE on CMR is an imaging criterion for myocarditis, and pericardial oedema and/or LGE is one for pericarditis.^[2]

ESC 2025 myocarditis and pericarditis: CMR rows

^[2]

The 2021 AHA/ACC chest pain guideline gives its own rows for this setting; its recommendation table for acute chest pain with suspected myopericarditis includes the two CMR rows below.^[13]

AHA/ACC 2021 chest pain: CMR rows for acute chest pain with suspected myopericarditis

^[13]

In its supportive text, AHA/ACC 2021 says CMR with late gadolinium enhancement can show characteristic changes of acute myopericarditis, especially if performed early, within 2 weeks of the index presentation.^[13] Among the guidelines checked for this topic, no newer AHA/ACC guideline gives a CMR row for suspected myopericarditis; the ESC 2025 rows above are the ESC rows for the same question.

What the scan says about prognosis

ESC 2025 says myocarditis patients with normal CMR have a good prognosis, and that LGE on CMR at initial presentation is an important prognostic finding.^[2] It reports a multicentre study of acute myocarditis with preserved EF in which anteroseptal mid-wall LGE was the best independent predictor of the combined endpoint.^[2] That endpoint was cardiac death, appropriate ICD interventions, resuscitated cardiac arrest and HF hospitalisation, reached by 7.7% at a median 4.3 years.^[2] ESC 2026 HF says myocarditis with extensive LGE on CMR should be viewed as high risk, as should presentations with decompensated HF, LVEF below 40% or life-threatening arrhythmias.^[3]

The pericardium

In pericarditis, ESC 2025 says CMR detects thickening, oedema and LGE of the pericardium.^[2] It warns that pericardial LGE may imply ongoing inflammation and neovascularisation rather than simple scarring.^[2] CMR helps assess the degree of inflammatory involvement of the pericardium objectively, either at first diagnosis or at follow-up (ESC 2025).^[2] Treatment of pericarditis is in Acute pericarditis: diagnosis and colchicine.

Cardiac sarcoidosis

ESC 2025 says that, compared with FDG-PET, CMR has higher sensitivity (89%–95% vs 84%) but similar specificity (78%–85% vs 82%) for diagnosing cardiac sarcoidosis.^[2] A heavy burden of LGE is associated with a poorer prognosis and predisposes to VA, HF and death in cardiac sarcoidosis, and may guide clinical decision-making (ESC 2025).^[2] ESC 2025 Recommendation Table 17 says an ICD should be considered in cardiac sarcoidosis with LVEF above 35% after the active phase if there is significant LGE, among other listed features (Class IIa, Level C).^[2]

Troponin rise with non-obstructive coronary arteries (MINOCA)

In ESC 2023 ACS, MINOCA (myocardial infarction with non-obstructive coronary arteries) means symptoms suggestive of ACS, a troponin elevation and non-obstructive coronary arteries at angiography, defined as stenosis <50% in any major epicardial vessel.^[14] When a diagnosis is not established after coronary angiography, ESC 2023 calls MINOCA a working diagnosis as opposed to a final diagnosis.^[14] The Fifth Universal Definition of Myocardial Infarction (2026) updates the definition of MINOCA to "myocardial injury with non-obstructive coronary arteries".^[16] It says the term can be applied as a working diagnosis when a patient with clinical features of possible MI is then found to have non-obstructive coronary arteries (no stenosis ≥50%) on coronary angiography.^[16] The older term referred to myocardial infarction rather than myocardial injury, which it calls problematic because most of these patients turn out to have a non-coronary cardiac cause (such as myocarditis, Takotsubo syndrome or cardiomyopathy) or a non-cardiac cause such as pulmonary embolism.^[16]

ESC 2023 says that if the underlying cause is not established using functional coronary angiography, non-invasive imaging (echocardiography, CMR, CT) is recommended, as clinically appropriate (narrative; no class or level given).^[14] It calls CMR one of the key diagnostic tools to determine the underlying cause of MINOCA.^[14] ESC 2023 says CMR can identify the underlying cause in up to 87% of patients with a working diagnosis of MINOCA.^[14] It says CMR should be performed in these patients as soon as possible after presentation to maximise its diagnostic yield, ideally during the index admission.^[14]

ESC 2023 ACS Recommendation Table 13: myocardial infarction with non-obstructive coronary arteries (all three rows)

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For patients with non-obstructive coronary arteries, the Fifth UDMI (2026) calls CMR the modality of choice to confirm the diagnosis of MI, but says it more often identifies an alternative cause of acute myocardial injury, such as myocarditis or Takotsubo syndrome.^[16] It says clinical practice guidelines recommend CMR to aid in establishing the final diagnosis, ideally within 2 weeks after presentation but thereafter if necessary.^[16] The diagnostic yield of CMR is higher within 2 weeks of presentation because, after that, reversible myocardial changes may resolve, particularly in Takotsubo syndrome or acute myocarditis (Fifth UDMI).^[16]

AHA/ACC 2021 chest pain: CMR rows for acute chest pain with myocardial injury or a positive troponin and nonobstructive coronary arteries

^[13]

ACC/AHA 2025 ACS says the diagnostic evaluation of chest pain and the management of type 2 MI, spontaneous coronary artery dissection and MINOCA are covered in separate documents.^[15] For the evaluation of chest pain, it points to the 2021 chest pain guideline.^[15] So, among the guidelines checked for this topic, the 2021 rows above are the AHA/ACC rows for this setting.

Amyloid on CMR

ESC 2026 HF says cardiac amyloidosis should be suspected in patients with HF and increased LV wall thickness in the presence of specific red flags, particularly in patients aged over 65 years.^[3] Its Table 20 lists four CMR red flags, each marked for both TTR and AL amyloidosis.^[3] A footnote to that table says CMR can be diagnostic for cardiac amyloidosis.^[3]

CMR rows of ESC 2026 HF Table 20 (red flags for the most common forms of cardiac amyloidosis)

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ESC 2023 explains the kinetics: amyloid often gives global, subendocardial or segmental LGE with a highly specific myocardial and blood-pool gadolinium pattern caused by similar myocardial and blood T1 signals.^[1]

In the ESC 2023 diagnostic criteria, echocardiographic or CMR findings appear in combination: with an extracardiac amyloid biopsy on the invasive route, or with grade 2 or 3 bone-scintigraphy uptake and exclusion of a clonal dyscrasia on the non-invasive route.^[1] ESC 2026 HF says invasive diagnostic criteria apply to all forms, whereas non-invasive criteria are accepted only for transthyretin amyloidosis (ATTR).^[3] In ESC 2023, the invasive route accepts an extracardiac amyloid biopsy accompanied by characteristic features on echocardiography or CMR.^[1] Its non-invasive route combines typical echocardiographic/CMR findings with grade 2 or 3 radiotracer uptake on bone scintigraphy and exclusion of a clonal dyscrasia.^[1]

For underlying aetiology in HFpEF or HFrEF, ESC 2026 HF recommends initial testing with serum and urine immunofixation, a serum free light chain assay and DPD/PYP/HMDP bone scintigraphy in patients with HF and a suspicion of cardiac amyloidosis (Class I, Level B).^[3] For follow-up, ESC 2023 says contrast-enhanced CMR should be considered for the serial follow-up and assessment of therapeutic response in patients with cardiac amyloidosis, Anderson–Fabry disease, sarcoidosis, inflammatory cardiomyopathies, and haemochromatosis with cardiac involvement (Class IIa, Level C).^[1] Its follow-up text gives evaluation of ECV in amyloidosis as an example.^[1] In severe renal impairment, ESC 2023 says non-contrast CMR modalities and mapping are particularly valuable when assessing Anderson–Fabry disease and cardiac amyloidosis.^[1] The full work-up and therapy are in Cardiac amyloidosis: AL vs ATTR, imaging, tafamidis.

HCM: diagnosis and LGE as a risk marker

AHA/ACC 2024 calls CMR a complementary technique in HCM for diagnosis, risk prediction and planning of septal reduction therapy.^[7] ESC 2023 says CMR is recommended in patients with HCM at their baseline assessment.^[1] ESC 2023 Table 17 says CMR is superior in detecting LV apical and anterolateral hypertrophy, aneurysms and thrombi.^[1] AHA/ACC 2024 says maximal LV wall thickness can be underestimated (or overestimated) with echocardiography compared with CMR.^[7]

AHA/ACC 2024 HCM: recommendations for CMR imaging (all five rows)

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ESC 2023 Recommendation Table 17 adds that contrast-enhanced CMR may be considered before alcohol septal ablation or myectomy to assess the extent and distribution of hypertrophy and myocardial fibrosis (Class IIb, Level C).^[1]

How LGE enters the ICD decision

ESC 2023 and AHA/ACC 2024 each give extensive LGE a conditional role in the HCM ICD decision (rows below).^[1][7] ESC 2023 places it within shared decision-making in the low-risk category (<4% estimated 5-year risk of SCD); AHA/ACC 2024 applies it in select adults without major SCD risk factors or in whom the decision remains otherwise uncertain.^[1][7] AHA/ACC 2024 Table 8 defines extensive LGE as replacement fibrosis, quantified or estimated by visual inspection, comprising ≥15% of LV mass.^[7] That table notes the extent of LGE conferring risk has not been defined in children.^[7] AHA/ACC 2024 says studies have promoted the ≥15% threshold as a significant (2-fold) increase in SCD risk, but no consensus on the optimal quantification technique has been reached.^[7]

Where LGE appears in the HCM ICD rows

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ESC 2023 reports a meta-analysis of nearly 3000 HCM patients from several studies (follow-up not stated in the guideline) suggesting LGE is associated with a 2.32-fold increased risk of SCD, aborted SCD or appropriate ICD discharge.^[1] The same meta-analysis suggests a 2.1-fold increase in all-cause mortality.^[1]

Absence of (or minimal) LGE is associated with lower risk of SCD (AHA/ACC 2024).^[7] ESC 2023 says the absence of fibrosis may help separate HCM from athletic adaptation, but LGE may be absent in HCM, particularly in young people and mild disease.^[1] ESC 2023 also says the 2-standard deviation technique is the only LGE quantification method validated against necropsy.^[1] The full SCD algorithm is in Hypertrophic cardiomyopathy.

LGE in DCM and NDLVC ICD rows

In ESC 2023 Recommendation Table 24, the footnote to the DCM row without a high-risk genotype says additional risk factors include syncope and LGE presence on CMR.^[1]

• ESC 2023 (Class IIa, Level C): an ICD should be considered in patients with DCM with a genotype associated with high SCD risk and LVEF >35% in the presence of additional risk factors (see ESC 2023 Table 21).^[1]
• ESC 2023 (Class IIb, Level C): an ICD may be considered in patients with DCM without a genotype associated with high SCD risk and LVEF >35% in the presence of additional risk factors.^[1]

Stress CMR for ischaemia

ESC 2024 says CMR perfusion relies on the first-pass myocardial perfusion of gadolinium-based contrast agents, and that visual assessment of perfusion defects is currently used in clinical practice.^[4] It combines high spatial resolution with the absence of ionising radiation (ESC 2024).^[4] A multiparametric protocol, including LV function and LGE with perfusion, increases the ability to rule in or rule out obstructive CAD in suspected CCS (ESC 2024).^[4]

Ischaemia rows that name CMR, by body and year

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How the AHA/ACC 2021 and 2023 rows fit together

The AHA/ACC 2023 CCD and 2021 chest pain sets are written for differently defined patients, and the groups can overlap, so both are given.^[8][13] The 2023 CCD rows are written for patients with CCD.^[8] That guideline is intended to apply in the outpatient setting to listed categories of patients.^[8] These include patients with stable angina symptoms (or ischaemic equivalents such as dyspnoea or arm pain with exertion) medically managed with or without positive results of an imaging test, and patients with angina symptoms and evidence of coronary vasospasm or microvascular angina.^[8] Two of the 2021 chest pain rows above are written for intermediate-risk acute chest pain with no known CAD: one for patients eligible for cardiac testing, one for those with an inconclusive CCTA.^[13] Two more are written for intermediate-high-risk stable chest pain with no known CAD, and for intermediate-risk acute chest pain with known CAD and new onset or worsening symptoms.^[13] The other two 2021 rows there are written for stable chest pain symptoms with known extensive nonobstructive CAD, and for persistent stable chest pain with nonobstructive CAD.^[13] Where a patient meets the conditions of rows in both sets, this page gives each row with its own condition and class.^[8][13] The AHA/ACC/HFSA 2022 HF row in the same table is written for patients with HF and CAD who are candidates for coronary revascularisation.^[17]

The 2021 guideline revises known CAD to include patients with prior anatomic testing (invasive angiography or CCTA) with identified nonobstructive atherosclerotic plaque and obstructive CAD; it uses obstructive for ≥50% stenosis and nonobstructive for <50%.^[13] AHA/ACC 2023 CCD refers readers to the 2021 chest pain guideline for additional recommendations on topics that include known obstructive and nonobstructive CAD, suspected ischaemia and INOCA.^[8] For nonobstructive CAD imaging recommendations, it points to its own Section 3.1 (Diagnostic Evaluation) and to the 2021 chest pain guideline.^[8]

AHA/ACC 2023 CCD footnotes its two CMR rows in the table above as modified from the 2021 chest pain guideline, where "modified" means formatting changes (eg, minor modifications such as PICO[TS] structure), whereas a change in COR or LOE is classed as "adapted".^[8] For patients with CCD, this page therefore teaches the 2023 wording, and the two 2021 rows that name CMR for obstructive CAD with stable chest pain appear below only as dated history.^[8][13]

• AHA/ACC 2021, dated history for patients with CCD (COR 1, LOE B-NR): the row read "for patients with obstructive CAD who have stable chest pain despite optimal GDMT, stress PET/SPECT MPI, CMR, or echocardiography is recommended for diagnosis of myocardial ischemia, estimating risk of MACE, and guiding therapeutic decision-making".^[13]
• AHA/ACC 2021, dated history for patients with CCD (COR 2a, LOE B-NR): the row read "for patients with obstructive CAD who have stable chest pain symptoms undergoing stress PET MPI or stress CMR, the addition of MBFR is useful to improve diagnosis accuracy and enhance risk stratification".^[13]

What counts as high risk on stress CMR

ESC 2024 Recommendation Table 14 recommends using one or more listed test results to identify individuals at high risk of adverse events (Class I, Level B).^[4] For stress CMR, the threshold is ≥2 of 16 segments with stress perfusion defects or ≥3 dobutamine-induced dysfunctional segments.^[4] In those at high risk, regardless of symptoms, ESC 2024 recommends invasive coronary angiography, with FFR/iFR when appropriate, to refine risk stratification and improve symptoms and outcomes by revascularisation (Class I, Level A).^[4]

High-risk test results in ESC 2024 Recommendation Table 14 (all five listed tests)

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ESC 2024 lists the limits of stress CMR as limited availability, claustrophobia, acquisition time and possible contraindications, such as non-conditional pacemakers and ICDs, or renal failure for gadolinium.^[4] Unlike SPECT/CT or PET-CT, stress CMR does not currently give information on coronary calcification (ESC 2024).^[4] ESC 2024 still calls coronary MR angiography primarily a research tool.^[4]

AHA/ACC 2023 Table 5 lists reduced LV and/or RV EF, LV hypertrophy, scar or infarct, reduced myocardial perfusion reserve and myocardial blood flow at stress as CMR features potentially associated with a higher risk of MACE in patients with established CCD.^[8] AHA/ACC 2023 also says that, in patients with CCD, if there is an opportunity to do so, clinicians should first intensify GDMT and defer testing.^[8] Choosing between CCTA and functional testing is in Chronic coronary syndromes: pre-test likelihood, the CCTA pathway and treatment, and the wider chest pain work-up is in Chest pain evaluation.

Viability: what the trials now say

Viability imaging looks for hibernating myocardium that might recover after revascularisation.^[4] ESC 2024 CCS says low-dose dobutamine echo, CMR and PET/CT can identify hibernating myocardium with the potential for functional recovery after revascularisation.^[4] But ESC 2026 HF says evidence supporting viability testing to identify suitable patients for revascularisation is lacking.^[3]

• REVIVED-BCIS2 main trial (as ESC 2024 reports it): a randomised trial of 700 patients with impaired LV function (EF ≤35%), extensive CAD amenable to PCI and evidence of viability in at least four dysfunctional segments, PCI plus GDMT vs GDMT alone; after a 3.4-year follow-up, PCI showed no significant reduction in the composite primary endpoint of all-cause death or HF rehospitalisation (HR 0.99; 95% CI, 0.78–1.27).^[4]
• REVIVED-BCIS2 viability analysis (JAMA Cardiol 2023): a prespecified secondary analysis of the prospective open-label REVIVED-BCIS2 randomised trial of revascularisation or medical therapy (40 UK centres), including 610 of the 700 randomised patients, all with LVEF ≤35%, extensive CAD and evidence of viability in at least 4 myocardial segments that were dysfunctional at rest, whose viable and nonviable myocardium was quantified by blinded core-laboratory analysis of CMR scans and dobutamine stress echocardiograms; median follow-up 3.4 years.^[11]
• Its result: no interaction between the extent of viable or nonviable myocardium and the effect of PCI on the analysis's primary outcome (the composite of all-cause death or hospitalisation for HF) or on any secondary outcome; the authors conclude viability testing does not identify patients with ischaemic cardiomyopathy who benefit from PCI, while the extent of nonviable myocardium, but not of viable myocardium, is associated with event-free survival and likelihood of improvement of LV function.^[11]
• ESC 2024 on that analysis: larger amounts of non-viable myocardium were linked to an increased risk of the primary outcome regardless of PCI, suggesting viability assessment may be useful for risk stratification.^[4]
• STICH (as ESC 2024 reports it): a randomised trial of 1212 patients with CAD without left main disease, eligible for CABG and with LVEF ≤35%, comparing CABG plus GDMT with GDMT alone; viability was assessed by SPECT, dobutamine echo or both in 50% of patients, with no significant interaction between viability and improved LV function or long-term survival benefit from CABG above GDMT.^[4]

A later REVIVED-BCIS2 report examined ischaemic burden on stress perfusion CMR in a subset of the trial patients with ischaemic left ventricular dysfunction.^[12] This post hoc analysis of REVIVED-BCIS2 in ischaemic left ventricular dysfunction (Eur Heart J 2025) included 181 patients who had stress perfusion CMR of sufficient diagnostic quality before randomisation.^[12] On CMR, scar burden was 18% [9–26] and ischaemic burden 31% [12–56].^[12] This analysis defined its own primary composite outcome as all-cause death or aborted sudden death (an appropriate ICD therapy or a resuscitated cardiac arrest).^[12] Across the cohort, ischaemic burden was not associated with that primary outcome (HR 1.00 per 10% increase in ischaemic burden).^[12] The authors saw no association between ischaemic burden, clinical outcomes and randomised treatment assignment; primary outcome events were counted at a median of 42 months.^[12] The authors note ischaemia testing was discretionary, so the analysis contains only 26% of the trial population.^[12]

ESC 2024 concludes that many open questions remain on how viability should be defined, and when and why it should be assessed in ischaemic HFrEF.^[4] For the initial diagnostic work-up of suspected CCS, ESC 2024 says functional imaging should be selected as a first-line test if information on myocardial ischaemia, viability or microvascular disease is desired.^[4]

Valve disease

ACC/AHA 2020 and ESC/EACTS 2025 both give formal rows that name CMR in valve disease; ESC/EACTS 2025 also gives CMR narrative roles, with no class or level given for those statements.^[18][5]

Valve rows that name CMR, by body and year

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ESC/EACTS 2025 says that in patients with regurgitant lesions, particularly aortic regurgitation (AR), CMR has gained key value in clinical practice.^[5]

• AR (ESC/EACTS 2025): 3D echocardiography and CMR allow more accurate evaluation of LV volumes and LVEF than 2D echocardiography and are useful in borderline cases; a CMR LVESVi ≥43 mL/m² was recently proposed to guide management of asymptomatic patients.^[5]
• AR fibrosis (ESC/EACTS 2025): myocardial fibrosis detected by CMR needs to be integrated in decision-making, even if not entirely validated yet.^[5]
• Primary MR (ESC/EACTS 2025): CMR is an alternative to precisely quantify regurgitant volume and fraction when measurements are inconclusive or discordant, and the gold standard for chamber volumes.^[5]
• Mitral annular disjunction (ESC/EACTS 2025): in Barlow's disease with mitral annular disjunction, CMR-detected fibrosis has been associated with ventricular arrhythmias and sudden cardiac death.^[5]
• Secondary MR (ESC/EACTS 2025): the extent of myocardial fibrosis on CMR has been associated with poor prognosis.^[5]
• Aortic stenosis (ESC/EACTS 2025): CMR identifies remodelling and quantifies scarring and diffuse fibrosis, which are associated with adverse events.^[5]
• Tricuspid regurgitation (ESC/EACTS 2025): when accurate RV size, function and volume are needed for decisions, CMR should be used because of its high accuracy and reproducibility.^[5]

Safety: devices, gadolinium and pregnancy

Cardiac devices

ESC 2021 says MRI in pacemaker patients may cause adverse effects such as inappropriate device function due to device reset or sensing problems, or interaction with the magnetic reed switch.^[9] Its other examples are induced currents resulting in myocardial capture, heating at the lead tip with changes in sensing or capture thresholds, or lead perforation.^[9] ESC 2021 says it is the entire CIED system (generator and leads, which need to be from the same manufacturer) that determines MRI conditionality, and not the individual elements.^[9] ESC 2021 says that, in general, MRIs should always be performed within a rigorously applied standardised institutional workflow, following the appropriate conditions of use (including programming).^[9]

ESC 2021: recommendations for performing MRI in pacemaker patients (all three rows)

^[9]

• Scanner limits for MRI-conditional systems (ESC 2021): ESC 2021 says most manufacturers now propose MRI-conditional devices, and MRI scans may be limited to 1.5 T and a whole-body specific absorption rate (SAR) <2 W/kg (head SAR <3.2 W/kg), but some models allow 3 T and up to 4 W/kg whole-body SAR.^[9]
• After implantation (ESC 2021): the manufacturer may specify an exemption period (usually 6 weeks), but it may be reasonable to scan earlier if clinically warranted.^[9]
• Abandoned transvenous leads (ESC 2021): 1.5 T scans limited to SAR <1.5 W/kg may be considered in selected patients, taking into account the risk–benefit ratio, particularly if the scans are extrathoracic and patients are not pacemaker dependent.^[9]
• Epicardial leads, adaptors/extenders or damaged leads (ESC 2021): given the paucity of safety data, recommendations cannot be made at this stage.^[9]

^[9]

In their CMR sections, the ESC 2023 cardiomyopathies and ESC 2025 myocarditis and pericarditis guidelines add narrative statements on CMR with devices (no class or level given).^[1][2] ESC 2023 says CMR can be considered with conditional devices and nearly all non-conditional devices provided appropriate protocols are in place.^[1] ESC 2025 myocarditis and pericarditis says CMR could be used with non-conditional devices if there is a clear clinical indication and other imaging is not helpful.^[2] In all cases, programming of the device before and after the scan is warranted, as well as patient monitoring (ESC 2025 myocarditis and pericarditis).^[2]

ESC 2023 says solutions to reduce artefacts, including reducing inhomogeneity, technical adjustments and special sequences, reduce the rate of uninterpretable studies to one in five.^[1] In its nuclear medicine section, ESC 2025 myocarditis and pericarditis says FDG uptake reflects metabolically active inflammatory cells in acute myocarditis.^[2] It adds there that FDG-PET can be considered as an alternative in patients when CMR is unsuitable because of an irregular heartbeat or device-related artefacts.^[2] Device indications are in ICD and CRT indications in heart failure.

Gadolinium and the kidney

ESC 2023 says nephrogenic systemic fibrosis is a rare complication reported with first-generation linear unstable gadolinium chelates and severe renal disease.^[1] Gadolinium-based agents can be safely given with an eGFR above 30 mL/min/1.73 m², and the complication is virtually unreported with newer linear or macrocyclic agents (ESC 2023).^[1] In severe renal impairment, ESC 2023 says non-contrast CMR modalities and mapping are particularly valuable when assessing Anderson–Fabry disease and cardiac amyloidosis.^[1]

Pregnancy and lactation

ESC 2025 pregnancy says CMR is advised if other non-invasive measures cannot give a clinical diagnosis, and is preferable to radiation-based imaging.^[10] It seems prudent to avoid a scanner strength above 1.5 tesla because of greater energy deposition in tissue (ESC 2025).^[10] Evidence on gadolinium in pregnancy is controversial, and its use should be avoided unless absolutely necessary (ESC 2025).^[10]

• ESC 2025 pregnancy (Class IIa, Level C): CMR imaging without gadolinium contrast should be considered for a definitive, clinically relevant diagnosis during pregnancy, if other non-invasive diagnostic measures are not sufficient.^[10]
• ESC 2025 pregnancy (Class IIa, Level C): discontinuation of lactation for 24 h should be considered in women in whom i.v. gadolinium is required.^[10]
• ESC 2023 cardiomyopathies: the use of gadolinium contrast is generally not advised in pregnancy due to the potential for adverse outcomes in the foetus and neonate.^[1]

Pitfalls

Special populations

• Children (ESC 2023): rapid CMR techniques allow scans without general anaesthesia even in very young children; where anaesthesia is needed, the relative risks and benefits should be considered.^[1]
• Children with HCM (AHA/ACC 2024): CMR may be helpful but may require sedation, whose risk may outweigh the benefit in an asymptomatic child; the physician and family decide after weighing the child's risk.^[7]
• Children with HCM (ESC 2023): there are very limited data on CMR over validated risk algorithms for SCD prediction.^[1]
• Pregnancy (ESC 2025 pregnancy): CMR without gadolinium contrast should be considered for a definitive, clinically relevant diagnosis during pregnancy if other non-invasive diagnostic measures are not sufficient (Class IIa, Level C); ESC 2025 says gadolinium should be avoided unless absolutely necessary.^[10]
• Severe renal impairment (ESC 2023): non-contrast CMR modalities and mapping are particularly valuable when assessing Anderson–Fabry disease and cardiac amyloidosis; gadolinium-based contrast agents can be safely administered with eGFR above 30 mL/min/1.73 m².^[1]
• Who may not be scanned (AHA/ACC 2024): CMR may not be feasible because of availability, cost, pacemakers or ICDs, severe renal insufficiency, or patient factors such as sedation needs, claustrophobia or body habitus.^[7]
• Intubated patients (ESC 2025): CMR scans are feasible to detect inflammation.^[2]

Evidence, guidelines and regional differences

^{[1] [4] [14] [7] [8] [13] [17] [18]}

On repeat imaging, the bodies differ in strength and interval.^[1][7] ESC 2023 says contrast-enhanced CMR should be considered in cardiomyopathy during follow-up to monitor disease progression and aid risk stratification and management (Class IIa, Level C), and describes serial imaging every 2–5 years depending on initial severity and clinical course.^[1] AHA/ACC 2024 says repeat contrast-enhanced CMR on a periodic basis (every 3-5 years) in HCM for the purpose of SCD risk stratification may be considered (COR 2b, LOE C-EO).^[7]

Other guideline rows that name CMR, by guideline

Other guideline rows that name CMR, by guideline

^{[2] [10] [1] [14] [6] [25] [9] [26] [7] [21] [13] [27] [30]}

In Australia and New Zealand

For Australia and New Zealand, the NHFA/CSANZ 2018 heart failure guideline (Heart Lung Circ) gives three GRADE-graded rows that name CMR; all three are given in full as dated 2018 rows in the table of other guideline rows.^[30] One is a strong recommendation FOR (low quality of evidence): CMR with LGE should be considered in patients with heart failure associated with increased LV wall thickness that remains unexplained following clinical evaluation including a 12-lead ECG and echocardiogram to identify inflammatory and infiltrative cardiomyopathies.^[30] Two are weak recommendations FOR: either CT coronary angiography or CMR with LGE may be considered in heart failure with a low-to-intermediate pretest probability of coronary artery disease, to distinguish ischaemic and non-ischaemic causes of ventricular dysfunction (low quality of evidence).^[30] Non-invasive functional testing, including CMR with LGE, may be considered in heart failure with established coronary artery disease for the assessment of myocardial ischaemia and viability, to determine the need for coronary revascularisation (weak recommendation FOR; very low quality of evidence).^[30] Each guideline in the Australian and New Zealand table of the guideline register has this status in the census for this topic:

• Heart failure: the NHFA/CSANZ 2018 heart failure guideline (Heart Lung Circ; PMID 30077227) is held as its version of record, and its three rows that name CMR are used above; its Med J Aust 2018 summary (PMID 30067937) is not used, because the full guideline is.^[30]
• Acute coronary syndromes: the Med J Aust summary (PMID 41693087) of the 2025 NHFA/CSANZ ACS guideline has no MINOCA or CMR statement; the full guideline (Heart Lung Circ 2025; PMID 40180468) is not held as text for this topic in its version of record, so nothing here comes from it.
• Atrial fibrillation: the NHFA/CSANZ 2018 atrial fibrillation guideline (Heart Lung Circ; PMID 30077228) is not held as text for this topic in its version of record; only its PubMed record and a slide set are held, and a slide set is not used as a source, so it was not checked for this topic and nothing here comes from it.
• Structural and valvular echocardiography: the 2024 CSANZ position statement on transthoracic echocardiography in structural and valvular heart disease in adults (PMID 38749800) is not held as text for this topic in its version of record; only its PubMed abstract and a journal proof (article in press, not the version of record) are held, and a proof is not used as a source, so it was not checked for this topic, nothing here comes from it, and any CMR content it has is not covered here.
• Cardiovascular disease risk: for the 2023 Australian guideline for assessing and managing cardiovascular disease risk (Med J Aust; PMID 38623719), only its PubMed abstract is held; its full text is not held, so it was not checked for this topic and nothing here comes from it.
• Hypertension in pregnancy: for the Med J Aust summary of the 2023 SOMANZ hypertension in pregnancy guideline (PMID 38763516), only its PubMed abstract is held; its full text is not held, and the full guideline is not held as text for this topic, so neither was checked for this topic and nothing here comes from them.

The practice case for this topic is set in Australia and uses rows that include the ESC 2021 pacemaker row, the ESC 2026 HF amyloid testing row and the ESC 2023 serial follow-up CMR row.^[9][3][1]

Guidelines checked for this topic

Rows on this page come from the ESC 2023 cardiomyopathies, ESC 2025 myocarditis and pericarditis, ESC 2026 HF, ESC 2024 CCS, ESC 2023 ACS, ESC 2022 VA, ESC 2021 pacing and CRT, and ESC 2025 pregnancy guidelines, and from the ESC/ERS 2022 pulmonary hypertension guideline.^{[1][2][3][4][14][6][9][10][25]} AHA/ACC rows come from the 2024 HCM, 2023 chronic coronary disease, 2022 HF (AHA/ACC/HFSA) and 2021 chest pain guidelines, the ACC/AHA 2020 valve guideline and the ACC/AHA/HRS 2018 bradycardia guideline.^{[7][8][17][13][18][27]} Population rows also come from the ACC/AHA 2022 aortic disease guideline (pregnancy) and the ACC/AHA 2025 adult congenital heart disease guideline (repaired TOF).^[21][26] Valve rows and statements also come from ESC/EACTS 2025.^[5] ANZ rows come from the NHFA/CSANZ 2018 heart failure guideline.^[30] Each is the newest guideline of its body in its area among the guidelines checked for this topic (census 2026-10-09). The ACC/AHA/HRS 2018 bradycardia and cardiac conduction delay guideline is one of two 2018 guidelines used here, both older than the others.^[27] The census for this topic (PubMed, 2026-10-09) found no newer ACC/AHA guideline on bradycardia or conduction delay, so its two rows are given in the table of other guideline rows as dated 2018 rows, separately from the ESC 2021 pacing row.^[27][9] The other is the NHFA/CSANZ 2018 heart failure guideline; the guideline register lists no newer NHFA/CSANZ heart failure guideline, so its three rows are given in the same table as dated 2018 rows.^[30] Two newer documents were also checked for the MINOCA and chest pain rows.^[16][15] The Fifth Universal Definition of Myocardial Infarction (2026) updates the MINOCA definition, and the ACC/AHA 2025 ACS guideline says the diagnostic evaluation of chest pain and the management of MINOCA are covered in separate documents.^[16][15] ESC 2026 HF Table 6 lists three 2021 ESC HF CMR rows (poor acoustic windows; tissue characterisation; LGE in DCM) as revised into one contrast-enhanced CMR row (Class I, Level C), so those 2021 rows appear here only as history.^[3] The census for this topic and the guideline register also identified the guidelines listed below, whose version of record is not held; they were not checked for this topic, none of their rows are used, and any CMR rows in them are not covered. The ANZ guidelines from the guideline register that were not checked for this topic are listed, each with its status, in the Australia and New Zealand section above.

• The 2021 ACC/AHA/SCAI guideline for coronary artery revascularization (PMID 34882435) is not held as text, so it was not checked for this topic.
• The 2018 ESC/EACTS guidelines on myocardial revascularization (PMID 30165437) are not held as text, so they were not checked for this topic; the held ESC 2024 CCS guideline says: "These guidelines update and replace the previous version from 2019 and partly replace the myocardial revascularization guidelines from 2018."^[4]
• The 2022 ESC guidelines on cardio-oncology (PMID 36017568) are not held as text, so they were not checked for this topic.
• For the 2024 ACC/AHA multisociety guideline for the management of lower extremity peripheral artery disease (PMID 38743805), only its PubMed abstract is held; its full text is not held, so it was not checked for this topic.
• The 2026 ESC guidelines for the management of cardiovascular disease and chronic kidney disease (PMID 42661426) are not held as their version of record; only the ESC slide set is held, and a slide set is not used as a source, so they were not checked for this topic.
• For the 2026 AHA/ACC multisociety guideline for perioperative cardiovascular management for noncardiac surgery, which SCMR co-authored (PMID 42804570; JACC version PMID 42813718), only its PubMed abstract is held, as the abstract of the JACC version; its full text is not held, so it was not checked for this topic.

Other held guidelines, and one held AHA/ACC scientific statement, were checked; they are not used, or are used only for the populations above, because their remaining CMR or MRI content sits outside this topic.^{[19][26][20][29][21][22][23][24][28]}

• ESC 2020 adult congenital heart disease (PMID 32860028) uses CMR across congenital lesions, for example for systemic RV systolic function and atrial baffle patency; congenital heart disease is not covered here apart from repaired TOF.^[19]
• The same ESC 2020 guideline has two repaired TOF rows that name extensive RV scarring on CMR among the risk factors (electrophysiologic evaluation for SCD risk stratification; ICD implantation in selected TOF patients with multiple risk factors); they are not used, because the newer ESC 2022 VA Recommendation Table 38 rows on PES and ICD implantation after TOF repair are given in the table of other guideline rows.^[19][6]
• ACC/AHA/HRS/ISACHD/SCAI 2025 adult congenital heart disease (PMID 41411375) is used for repaired TOF only; its other CMR rows concern other congenital lesions, for example: in adults with an unrepaired ASD, CMR imaging, transesophageal echocardiography, or cardiac CT is recommended to define defect size, morphology, rim anatomy, and pulmonary venous connections (COR 1, LOE B-NR).^[26]
• The same guideline says valvular heart disease may be congenital, so management overlaps with the 2020 ACC/AHA valve guideline, particularly for BAV disease; its rows that name CMR are written for adults with congenital heart lesions, and none is written for chronic aortic regurgitation or for primary or secondary mitral regurgitation, so it does not change the ACC/AHA 2020 valve rows above.^[26]
• ESC 2020 sports cardiology (PMID 32860412) lists CMR in its tables of recommendations for exercise, for example in individuals with myocarditis; those tables are held only as images, and exercise and sports participation are not covered here.^[20]
• The 2025 AHA/ACC scientific statement on competitive sports participation for athletes with cardiovascular abnormalities (PMID 39976316) gives clinical considerations without a class or level, for example that isolated LGE on CMR at the RV insertion points may be observed in competitive athletes and does not require further evaluation; it is a scientific statement, so no row is taken from it.^[29]
• ACC/AHA 2022 aortic disease (PMID 36322642) gives CT or MRI rows for imaging the aorta, for example in adults with Marfan syndrome after the initial TTE (COR 2a, LOE C-EO); aortic imaging, including in BAV, is not covered here apart from the pregnancy rows in the table of other guideline rows.^[21]
• The same guideline recommends TTE and cardiac MRI at diagnosis in Turner syndrome to evaluate for BAV, aortic root and ascending aortic dilation, aortic coarctation, and other congenital heart defects (COR 1, LOE B-NR); this congenital setting is not covered here.^[21]
• ESC 2024 peripheral arterial and aortic diseases (PMID 39210722) recommends duplex ultrasound as the first-line imaging method for PAD screening and diagnosis and CTA and/or MRA as adjuvant imaging; peripheral vascular imaging is not covered here.^[22]
• The same ESC 2024 guideline also says in its narrative that when TTE detects BAV-associated aortic dilatation, CCT or CMR is recommended to confirm measurements, exclude coarctation, and record baseline diameters at different levels for subsequent periodic assessments; aortic imaging outside pregnancy is not covered here.^[22]
• ESC 2023 endocarditis (PMID 37622656) recommends MRI or PET/CT in suspected spondylodiscitis and vertebral osteomyelitis complicating IE (Class I, Level C); spinal imaging is not covered here.^[23]
• ESC 2024 hypertension (PMID 39210715) names CT or magnetic resonance renal angiography as alternative testing options in its renal ultrasound and Doppler row (Class IIa, Level C); renal imaging is not covered here.^[24]
• ESC 2023 cardiovascular disease in patients with diabetes (PMID 37622663) has no recommendation row that names CMR, and peripheral vascular imaging is not covered here.^[28]
• The same guideline says duplex scan is the first-line imaging for confirming LEAD and should be performed at least when revascularization is indicated, and that magnetic resonance angiography or CT angiography can also help to plan further treatment.^[28]

Exam pearls

• Core protocol: ESC 2023 says initial CMR evaluation in cardiomyopathy should routinely include cine, T2-weighted, pre- and post-contrast T1 mapping and LGE, and T2* mapping should be employed when haemochromatosis is suspected.^[1]
• Updated Lake Louise criteria (ESC 2025): at least one T2-based plus ideally one T1-based criterion; proven = 2 of 2, uncertain = 1 of 2, rejected = negative CMR.^[2]
• HCM LGE (ESC 2023): present in 65% of patients (range 33–84%), typically patchy mid-wall in areas of hypertrophy and at the anterior and posterior RV insertion points.^[1]
• Fabry (ESC 2023): low non-contrast T1 and posterolateral LGE; amyloid: often global, subendocardial or segmental LGE with a highly specific gadolinium kinetic pattern.^[1]
• Extensive LGE as an HCM sudden death risk factor (AHA/ACC 2024 Table 8): replacement fibrosis comprising ≥15% of LV mass, quantified or estimated by visual inspection; the extent conferring risk has not been defined in children.^[7]
• Stress CMR result identifying high risk of adverse events (ESC 2024 Recommendation Table 14, where using the listed test results to identify such individuals is recommended, Class I, Level B): ≥2 of 16 segments with stress perfusion defects or ≥3 dobutamine-induced dysfunctional segments.^[4]
• MINOCA (ESC 2023 ACS Recommendation Table 13): in a working diagnosis of MINOCA, CMR imaging is recommended after invasive angiography if the final diagnosis is not clear (Class I, Level B); ESC 2023 says it should be performed as soon as possible after presentation, ideally during the index admission.^[14]
• Viability (ESC 2026 HF): evidence supporting viability testing to select patients for revascularisation is lacking.^[3]
• Pacemakers (ESC 2021): with an MRI-conditional system (an MRI-conditional generator and lead(s) from the same manufacturer), MRIs can be performed safely following the manufacturer's instructions (I A); with a non-conditional system, MRI should be considered if no alternative imaging mode is available and no epicardial, abandoned or damaged leads or adaptors/extenders are present (IIa B); with abandoned transvenous leads, MRI may be considered if no alternative imaging modality is available (IIb C).^[9]
• Gadolinium (ESC 2023): can be safely administered with eGFR above 30 mL/min/1.73 m²; nephrogenic systemic fibrosis is virtually unreported with newer linear or macrocyclic agents.^[1]

References30ShowHide

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2. [2]Schulz-Menger J, et al. 2025 ESC Guidelines for the management of myocarditis and pericarditis. Eur Heart J, 2025.PMID 40878297
3. [3]Køber L, et al. 2026 ESC Guidelines for the management of heart failure. Eur Heart J, 2026.PMID 42661420
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7. [7]Ommen SR, et al. 2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2024.PMID 38727647
8. [8]Virani SS, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2023.PMID 37480922
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11. [11]Perera D, et al. Viability and Outcomes With Revascularization or Medical Therapy in Ischemic Ventricular Dysfunction: A Prespecified Secondary Analysis of the REVIVED-BCIS2 Trial. JAMA Cardiol, 2023.PMID 37878295
12. [12]Morgan H, et al. Prognostic impact of inducible ischaemia in ischaemic left ventricular dysfunction: the REVIVED-BCIS2 trial. Eur Heart J, 2025.PMID 39661477
13. [13]Gulati M, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2021.PMID 34756653
14. [14]Byrne RA, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J, 2023.PMID 37622654
15. [15]Rao SV, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2025.PMID 40013746
16. [16]Mills NL, et al. Fifth Universal Definition of Myocardial Infarction (2026): On behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and the Society of Thoracic Surgeons (STS) Affirmation of Value by the Society for Cardiovascular Angiography and Interventions (SCAI). Glob Heart, 2026.PMID 42666939
17. [17]Heidenreich PA, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2022.PMID 35379503
18. [18]Otto CM, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2021.PMID 33342586
19. [19]Baumgartner H, et al. 2020 ESC Guidelines for the management of adult congenital heart disease. Eur Heart J, 2021.PMID 32860028
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21. [21]Isselbacher EM, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation, 2022.PMID 36322642
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25. [25]Humbert M, et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J, 2022.PMID 36017548
26. [26]Gurvitz M, et al. 2025 ACC/AHA/HRS/ISACHD/SCAI Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2026.PMID 41411375
27. [27]Kusumoto FM, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol, 2019.PMID 30412709
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