Cardiac MRI across ESC guidance in the last decade

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.