1. Ischemia-directed coronary revascularization: a cost effective role for routine cardiac magnetic resonance imaging? Nalyaka Sambu, Christopher Turner, Stephen Harden, Charles Peebles, Nick Curzen

2. NalyakaSambuMBBCh MRCP Wessex Cardiothoracic Unit Southampton University Hospitals NHS Trust UK No conflicts of interest to declare

4. Data from DEFER, FAME and COURAGE make a persuasive case for ischemia-directed percutaneous coronary intervention (PCI)

6. inadequate tool to detect objective evidence of ischemia

7. high rate of false positive, false negative and equivocal results

8. Other more superior tests are less widely available and more costly

9. Cardiac magnetic resonance imaging (CMR):

10. provides precise and superior quality images

11. higher sensitivity and specificity in detecting myocardial ischemia compared to stress echocardiography¹¹Mahrholdt H et al Heart 2007;93:122-29

13. To assess whether the routine use of CMR in patients with suspected angina:

14. has a significant impact on the management strategy in patients being considered for revascularization

16. A database was created which included:

17. clinical history

18. indication for CMR

19. CMR results

21. Index clinical presentation *Coronary angiogram

22. CMR results *Late gadolinium (GAD) enhancement

23. CMR REFERRAL PATHWAY 150 patient referrals 107 (71%) considered for revascularisation 17 (16%) considered for CABG 101 (94%) considered for PCI 11 (10%) considered for either CMR stress and gadolinium gadolinium only Viability confirmed in 1 ↓ CABG 32 (30%) had inducible ischemia revascularization deferred in 74 (70%) due to lack of ischemia 12 (11%) were deferred for other reasons 8 (7%) had minimal ischemia 12 (11%) underwent revascularization (10 PCI; 2 CABG)

27. CMR resulted in net cost savings of £362,016

28. CMR avoided unnecessary potential procedural risk associated with revascularization

30. Routine use of CMR to detect ischemiasignificantly influences the management of patients being considered for revascularization

31. Despite the relative expense of CMR, its routine use leads to significant overall cost savings

32. ETT is an unreliable non-invasive test of ischemia with low specificity for detecting myocardial ischemia