Cardiac magnetic resonance imaging to guide complex revascularization in stable coronary artery disease

Deciding whether to revascularize complex stable coronary disease is partly an anatomy question and partly a physiology one. This review argues cardiac MRI answers the physiology half better than the angiogram alone.

The authors make the case that MRI’s combined assessment of ischemia (is the muscle starved of blood under stress?) and viability (is it still salvageable?) identifies which patients actually stand to gain from a complex, risky procedure — information a purely anatomical picture of the narrowing can’t supply.

The practical takeaway is to pair functional MRI with anatomy when planning complex revascularization, selecting the patients most likely to benefit and sparing others. The resistance comes from an anatomy-first culture and the cost and workflow of adding MRI.

We rate the evidence moderate: a well-reasoned, conflict-free synthesis of prior studies, but no new data. Its clinical significance is moderate — better patient selection could avoid futile procedures, contingent on MRI access and expertise — and it foreshadows the broader lesson, later cemented by the ISCHEMIA trial, that physiology and symptoms should drive revascularization more than anatomy alone.