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CMR in Female Cardiovascular Disease

Non-Invasive Imaging

In this specific session 4 talks covered the role of CMR in female cardiovascular disease. The session was chaired by the program chairwoman Dr. Chiara Bucciarelli-Ducci, Bristol, UK and Dr. Sophia Mavrogeni from Athens, Greece.
In the first talk Holger Thiele covered potential differences of CMR for the assessment of stable and acute ischemic heart disease. In stable ischemic heart disease there are no relevant differences in the detection of coronary artery disease in female in comparison to male patients using stress perfusion imaging or dobutamine stress CMR. However, in comparison to SPECT imaging stress perfusion CMR turned out to be much better with respect to sensitivity and specificity as shown by Greenwood et al. Circulation 2014. In acute myocardial infarction several registries have shown higher mortality in woman in comparison to man. However, this is more a fact of baseline differences in female patients who often present later to the hospital, are often older, and more often have anterior myocardial infarction. After adjustment for baseline differences the mortality is usually the same. Myocardial salve as shown by CMR is similar in male and female patients (Eitel et al. Circulation Img 2012). However, acute coronary syndromes with normal coronary artery disease are mainly determined by female patients because they have more often apical ballooning syndrome where CMR is a very useful tool for the evaluation of differential diagnoses.
The next talk covered potential CMR indications for the noninvasive assessment of pulmonary artery hypertension given by Francisco Alpendurada, London, UK. Woman represent the majority of patients having pulmonary artery hypertension. There are multiple options of assessing pulmonary hypertension and its consequences on the right and left ventricular function.
Dr. Sophia Mavrogeni covered the role of CMR in patients with rheumatic diseases. Cardiac involvement is seen in different rates in Rheumatoid arthritis (RA) and other seronegative arthritis, Systemic lupus erythematosus (SLE), Small-medium-great vessels vasculitis, Inflammatory myopathies (IM), Systemic sclerosis (Scleroderma) (SSc), Mixted collagen diseases (MTCD), amyloidosis, and sarcoidosis.
CMR can offer multiple information in rheumatic disease. As indicated in the take-home message rheumatic diseases have:
  1. A silent cardiac presentation, but high mortality
  2. Currently used imaging techniques cannot detect cardiac pathophysiology in these diseases and therefore do not allow individualized patients’ risk stratification
  3. Currently used imaging techniques cannot identify cardiac disease acuity; most patients with rheumatic disease are female and unable to exercise; 4) Stress CMR offers a nonradiative option, without the limitations of acoustic window and/or breast artifacts, ideal for CAD and microvascular disease evaluation.
In the last talk for the first at EuroCMR the topic of CMR in pregnancy has been covered by Dr. Rory O’Hanlon, Dublin, Ireland. In general, CMR may be necessary in pregnancy in specific situations such as chronic cardiovascular and congenital heart disease; GUCH disease; valvular heart disease; cardiomyopathies, coronary artery disease, myocardial infarction, heart transplant recipients, arrhythmias, or aortic dissection. Before considering CMR in pregnancy the imaging physician should confer with the referring physician:
  1. The information requested from the CMR study cannot be acquired by means of nonionizing means (e.g. ultrasonography)
  2. The information is needed to potentially affect the care of the patient or fetus during the pregnancy
  3. The referring physician believes that it is not prudent to wait until the patient is no longer pregnant to obtain this data. Data on safety for the fetus are scarce and have been reviewed recently (De Wilde et al; Biophysics and Molecular Biology 2005).

In general, the shortest protocol with the lowest gradients should be applied. In an American College of Radiology Guidance Document on MR Safe Practices: 2013 by Kanal et al. it is also stated that MR contrast agents should not be routinely administered to pregnant patients. However, case-by-case decision by the senior MRI personnel is necessary and in case it is required this analysis should be able to defend a decision to administer the contrast agent based on overwhelming potential benefit to the patient or fetus outweighing the theoretical but potentially real risks of long-term exposure of the developing fetus to free gadolinium ions.  
In summary, a well-attended session with a lively discussion on the field of CMR in female cardiovascular disease.


CMR in Female Cardiovascular Disease
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.