Research Project Planning:

While a large number of projects aiming at comparative effectiveness of CMR in patient care is possible, some are considered higher in priority. The large datasets from the registry offers real-world evidence illustrating the potential impact by CMR on diagnostic and therapeutic thinking. These will need detailed sample size calculation and a budget to support specific personnel at all contributing sites is necessary. To name a few:

1) Assessment of the current published appropriate use criteria (AUC) of CMR: Published AUC represents recommendations from an expert panel and lags behind published or real-world evidence of a growing modality like CMR. It is anticipated that this project will identify a number of new CMR appropriate indications that lead to improvement of patient care.

2) Comparative diagnostic and therapeutic impact of CMR against echocardiography and routine angiography, in patients with heart failure with unknown etiology: This is one of the most common indications to performing CMR in experienced centers. Preliminary studies indicate that CMR serves as a new clinical gold standard diagnostic test given its ability to characterize tissue. In addition, current evidence suggests that invasive coronary angiography can be avoided in substantial subsets of these cases leading to reduction of patient morbidity and significant health care costs. Large data from the SCMR Registry will also gain new knowledge of the downstream patient outcomes and resource utilizations. It is estimated that 15-20% of all registry cases collected in the last 5 years, estimating 6,000+ CMR studies were performed for this indication.

3) Genetic basis, systemic manifestations, and prognosis of patients with non-ischemic cardiomyopathy: It is estimated that 60-70% of patients who develop a new onset cardiomyopathy has a genetic or familial basis but current genotype profiling of CMP patients results in useful clinical information in only approximately 10% of cases. Current treatment of CMP remains supportive only with no disease-reversing options. The problems lie in diverse genetic variability implicated in causing CMP, a relative lack of large population morphologic datasets, and a lack of physiologic profiling of myocardial tissue characteristics. LGE imaging by CMR is one of the most powerful method in diagnosing and prognosticating patients with CMP. Based on our recent survey, approximately 40% of all CMR cases performed in the last 10 years (estimating up to 19,000-21,000 CMR studies) were performed for contrast- enhanced assessment of CMP. This offers a unique opportunity to potentially gain invaluable new knowledge of CMP with implications to novel therapies.

4) Cost Effective Analysis of stress perfusion CMR in risk stratification of patients with chest pain syndromes: Chest pain syndromes account for 50% of all referrals for cardiac imaging. From our survey and data collected, there are 8,000-10,000 retrospective stress CMR studies performed for assessment of chest pain syndromes. Comparative cost effective analysis will provide insights in how the benefits of stress CMR (high resolution, a lack of radiation use) will benefit patient care, amongst other existing techniques. This type of data also serves as the main source of evidence that may escalate the AHA/ACC’s practice recommendations for stress CMR, from the current level IIa (reasonable evidence) to level I (multiple large-scale or randomized trial evidence).