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Randomized Controlled Trial
. 2025 Sep;13(9):102528.
doi: 10.1016/j.jchf.2025.102528. Epub 2025 Jul 12.

Cardiac Magnetic Resonance Imaging vs Coronary Angiography as Primary Strategy in Newly Diagnosed Heart Failure

Gülmisal Güder  1 , Theresa Reiter  2 , Wolfgang R Bauer  3 , Theano Papavassiliu  4 , Johannes Schwab  5 , Matthias Pauschinger  6 , Daniel Lavall  7 , Rolf Wachter  7 , Dominik Berliner  8 , Johann Bauersachs  8 , Stefan Frantz  3 , Götz Gelbrich  9 , Georg Ertl  10 , Stefan Störk  3
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Free article
Randomized Controlled Trial

Cardiac Magnetic Resonance Imaging vs Coronary Angiography as Primary Strategy in Newly Diagnosed Heart Failure

Gülmisal Güder et al. JACC Heart Fail. 2025 Sep.
Free article

Abstract

Background: New-onset heart failure with reduced ejection fraction (HFrEF) requires further diagnostic evaluation to determine its underlying cause. Despite the potential of cardiac magnetic resonance (CMR) imaging to identify ischemic and nonischemic causes, percutaneous invasive coronary angiography (CATH) remains the preferred tool for diagnosing ischemic cardiomyopathy (ICM).

Objectives: This study aimed to determine whether a CMR-first strategy could diagnose ICM as effectively as CATH (primary endpoint) and potentially reduce the number of invasive procedures (secondary endpoint).

Methods: In this multicenter 2-armed diagnostic trial (Magnetic Resonance Imaging vs Invasive Coronary Angiography as First-Line Diagnostic Modality in New-Onset Heart Failure), 229 adults with new-onset HFrEF were randomized to undergo CMR or CATH first and the other modality second. Separate expert panels evaluated both modalities, blinded to each other's results. The cardiologist-in-charge was blinded to the panel results and served as the reference standard.

Results: A total of 203 patients (mean age: 62 ± 14 years, 28% women) had evaluable pairs of diagnostic modalities (108 CATH-first). For diagnosing ICM, the panels considered CATH to be sufficient in 100% (105/105) and CMR in 80% (76/95; P < 0.001). Compared with the reference, sensitivity for diagnosing ICM was high for both (CATH 91%, CMR 90%; P = 1.00), but CMR had lower specificity (98% vs 74%; P < 0.001). According to the CMR panel, 48% (46/95) of CATH procedures could have been avoided with a CMR-first strategy, dropping to 45% when excluding patients who underwent coronary interventions.

Conclusions: Although CATH was superior for diagnosing ICM, CMR showed similar sensitivity and could significantly reduce CATH procedures without increasing the risk of missing critical coronary interventions. Longitudinal studies are needed to assess whether a CMR-first strategy confers prognostic benefit. (Magnetic Resonance Imaging vs Invasive Coronary Angiography as First-Line Diagnostic Modality in New-Onset Heart Failure; ISRCTN16515058).

Keywords: HFrEF; cardiac magnetic resonance; heart failure etiology; ischemic cardiomyopathy.

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Conflict of interest statement

Funding Support and Author Disclosures This trial was funded by an unrestricted grant from the German Cardiac Society (Düsseldorf, Germany). Dr Güder has received honoraria for lectures from Abbott, AstraZeneca, Bayer, Boehringer Ingelheim, and GlaxoSmithKline. Dr Reiter is supported by the German Research Foundation (SFB1525); and has received honoraria from Philips Health Care. Prof Bauer is a scientific advisor for Biotronik; and has received honoraria for lectures from Bristol-Myers Squibb, Pfizer, and Norvartis. Prof Pauschinger has received honoraria from AstraZeneca, Bayer, and Boehringer Ingelheim. Dr Lavall has received consulting fees and honoraria from AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, and Pfizer. Prof Wachter has received financial support from the German Research Foundation, the Federal Ministry of Education and Research, the European Union, the German Center for Cardiovascular Research, and Medtronic; and consulting fees and honoraria from AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, CVRx, Daiichi Sankyo, Medtronic, Novartis, Pharmacosmos, Pfizer, Servier, Sciarc, and Vifor. Dr Berliner has received honoraria from Abbott, AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Edwards Lifesciences, and Pfizer. Prof Bauersachs has received consulting fees and honoraria from Amgen, AstraZeneca, Bayer, Bristol Myers Squibb, Boehringer Ingelheim, Cardior, Corvia, CVRx, Edwards, Norgine, Novartis, Pfizer, Roche, and Vifor. Prof Störk has received financial support from the Federal Ministry of Education and Research, the European Union, and the German Center for Cardiovascular Research, and honoraria from AstraZeneca, Bayer, Boehringer Ingelheim, and Novartis. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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