In order to bring you the best possible user experience, this site uses Javascript. If you are seeing this message, it is likely that the Javascript option in your browser is disabled. For optimal viewing of this site, please ensure that Javascript is enabled for your browser.
Did you know that your browser is out of date? To get the best experience using our website we recommend that you upgrade to a newer version. Learn more.

The Myocardial Perfusion CMR versus Angiography and FFR to Guide the Management of Patients with Stable Coronary Artery Disease (MR-INFORM) trial

Giuseppe De Luca

Commented article by the ESC Working Group on Coronary Pathophysiology & Microcirculation

Coronary CT Angiography
Imaging of Acute Coronary Syndromes
CT-derived FFR
Cardiac Magnetic Resonance

Summary of the Original Article

The aim of the present study was to demonstrate whether a cardiovascular MRI–based strategy was non-inferior to an FFR based strategy with respect to major adverse cardiac events in patients with typical angina and either two or more cardiovascular risk factors or a positive exercise treadmill test. The authors performed an unblinded, multicenter trial by randomly assigning 918 patients to a cardiovascular MRI–based strategy or an FFR-based strategy. Revascularization was recommended for patients in the cardiovascular-MRI group with ischemia in at least 6% of the myocardium or in the FFR group with an FFR of 0.8 or less. The composite primary outcome was death, nonfatal myocardial infarction, or target-vessel revascularization within 1 year. The non-inferiority margin was a risk difference of 6 percentage points. A total of 184 of 454 patients (40.5%) in the cardiovascular-MRI group and 213 of 464 patients (45.9%) in the FFR group met criteria to recommend revascularization (P = 0.11). Fewer patients in the cardiovascular-MRI group than in the FFR group underwent index revascularization (162 [35.7%] vs. 209 [45.0%], P = 0.005). The primary outcome occurred in 15 of 421 patients (3.6%) in the cardiovascular-MRI group and 16 of 430 patients (3.7%) in the FFR group (risk difference, −0.2 percentage points; 95% confidence interval, −2.7 to 2.4), findings that met the noninferiority threshold. The percentage of patients free from angina at 12 months did not differ significantly between the two groups (49.2% in the cardiovascular-MRI group and 43.8% in the FFR group, P = 0.21).

Comments to the Article

This is a relevant clinical trial investigating two different diagnostic strategies in order to optimize the management of patients with typical angina and either two or more cardiovascular risk factors or a positive exercise treadmill test. The study was well conducted. The use of cardiovascular MRI dramatically reduced the number of coronary angiograms (48.2% vs 96.8% in FFR group), with subsequent less revascularizations in MRI group (35.7% vs 40.5%, p = 0.005). Unfortunately the authors missed a cost analysis, that would have certainly played in favour of the MRI-guided strategy. The two strategies were clinically equivalent in terms of primary endpoint (3.6% vs 3.7%). The non-inferiority of cardiovascular MRI guided vs FFR guided strategy was met, with a similar percentage of angina-free patients was observed in both groups at 1 year follow-up. It must be remarked that the authors compared two diagnostic rather than two therapeutic strategies. In fact, medical therapy was not maximized before randomization neither the authors investigated (by a special arm) the potential benefits of a conservative as compared to invasive strategy. Furthermore, no technical information was provided on percutaneous or surgical revascularization. Finally, a major limitation, well recognized by the authors, is that the expected event rate was much higher than the one finally observed (10% vs 3.7%), with a very large non inferiority margin (6%), much higher (almost double) than the final event rate. Therefore, future large and well powered trials with long-term follow-up are certainly needed in order to investigate these two strategies after maximization of medical therapy, especially in light of the results of the ISCHEMIA trial, and with a special regard to ACS patients with residual coronary disease after treatment of the culprit vessel.


  1. Hochman J. International Study of Comparative Health Effectiveness With Medical and Invasive Approaches: Primary Report of Clinical Outcomes.!/7891/presentation/35079
  2. Siebert VR, Borgaonkar S, Jia X, Nguyen HL, Birnbaum Y, Lakkis NM, Alam M.
    Meta-analysis Comparing Multivessel Versus Culprit Coronary Arterial Revascularization for Patients With Non-ST-Segment Elevation Acute Coronary Syndromes. Am J Cardiol. 2019 Nov 15;124(10):1501-1511.
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.