After 3 years and much debate, the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guidelines for the Evaluation and Diagnosis of Chest Pain were published this week. Based on contemporary evidence, these guidelines represent a significant shift towards the use of cross-sectional imaging compared to the previous 2012 guidelines, which advocated exercise treadmill testing for those physically able, with stress CMR being recommended in very limited clinical scenarios and with a lower class of recommendation than nuclear perfusion imaging and stress echo.

The new guidelines are very much patient-symptom focused and take into account cardiovascular risk and the impact of age, sex, and ethnicity. They also extensively consider the strengths and limitations of each of the four diagnostic imaging modalities to encourage an "appropriate choice" of diagnostic test in a range of clinical scenarios. Although it is impossible to summarise the whole guideline here or debate some of the particular recommendations around other modalities such as coronary computed tomography angiography (CCTA), I thought it would be useful to highlight how CMR has transitioned into a mainstream frontline investigation with its full adoption into US guidelines.

In terms of imaging recommendations for chest pain, the recommendations are broadly broken down into two scenarios: acute chest pain and stable chest pain. Within these two presentation scenarios, there are then specific recommendations based on whether the patient has known or no known coronary artery disease (CAD). Generally speaking, whilst CCTA features prominently in the algorithms, CMR has a Class 1 or Class 2a recommendation in all clinical scenarios and is now always at least equivalent to other functional imaging tests (stress echo, MPS-SPECT, PET). The table below summarises some of the pertinent CMR recommendations.

Although all guidelines lead to debate over the strength of recommendations and the underpinning evidence for certain statements, the current guideline generally reflects a more pragmatic approach to imaging investigation for chest pain, much like the 2019 ESC Guidelines for the Diagnosis and Management of Chronic Coronary Syndromes, and certainly not like the frequently criticised UK 2016 NICE Guideline for Chest Pain of Recent Onset: Assessment and Diagnosis.

Thus, for the CMR community, there is much to be celebrated, but we must also acknowledge and address the continuing evidence gaps that have limited some of our level of evidence statements, ideally before the next guideline writing group convenes.

Read the guidelines and register for the four-part guidelines webinar series here, and look for an upcoming editorial in the November 2021 issue of JCMR that will provide a further societal perspective.

John Greenwood, MBChB PhD FRCP FACC FSCMR

Do you love SCMR? Of course you do! With the end of the year approaching, now’s the time to renew! We have launched our new membership fees based on GDP, so no matter your location, it's a great time to take advantage of all that SCMR has to offer. Try re-engaging with our website, and enjoy discounts for Scientific Sessions, article submissions, and SCMR Workshops. Apply for your SCMR Letters of Verification or FSCMR for recognition of your dedication to the field! Don't forget to click on the Facebook and Twitter icons to stay updated between newsletters. Click here to renew—and above all, thank you all for your continued enthusiasm and advocacy for CMR!

SCMR recognizes the Fellows class of June 2021. The FSCMR designation distinguishes those with a significant level of involvement, dedication, and accomplishments consistent with the overall mission of the Society. The following FSCMR designees are recognized for their dedication to SCMR and the field of CMR:

The final 2021 deadline for the FSCMR program is 1 November. All applicants must be Regular or Technologist members of SCMR in good standing for the past 3 consecutive years with a distinguished record of CMR science, education, or clinical practice. Click here for details on FSCMR benefits and the application process.

As validation of this approach, Shenoy et al. recently published a large multicentre paper on patients undergoing clinical CMR for suspected cardiac tumor in European Heart Journal. The four centers that collaborated in the study were the University of Minnesota (PI Chetan Shenoy), Virginia Commonwealth University (PI John Grizzard), Houston Methodist Hospital (PI Dipan Shah), and Duke University (PI Raymond Kim). Data and images from the four centers were compiled using a cloud-based infrastructure from Heart Imaging Technologies, which is also currently used for the SCMR Registry.

SCMR is pleased to announce the call for this year's Seed Grant Program. The goal of the program is to foster the development of multi-site efforts for increasing the clinical effectiveness of CMR. The intention is to award one Basic Science and one Clinical Science Grant of up to $5,000 each in 2022, with some flexibility based on the nature of the application pool. Examples of possible topics include (but are not limited to) proposals to facilitate standardization or clinical evaluation of emerging CMR imaging biomarkers.

SCMR encourages early career investigators to identify pilot projects fostering multi-institutional collaborations leading to joint applications to established granting programs. Successful investigators will be invited to present their progress at the SCMR 26th Annual Scientific Sessions in 2023. More information on the Seed Grant Program and a link to apply can be found on the 2022 Scientific Sessions page.

In support of these agencies’ efforts, SCMR encourages CMR practitioners to use their relevant regional mechanisms for vaccine adverse event reporting (such as VAERS in the U.S.) to report any suspected cases with CMR findings if obtained. Also, the SCMR registry affords a platform for participating members to share images and clinical data with a global community.

Twitter-based #WhyCMR journal watch 📚⌚—join the online discussion!

1.    Valve disease with CMR—epic state-of-the-art review ☮️🧲✨

2.    Stress perfusion CMR—epic state-of-the-art review 😤🧲✨

3.   Post-STEMI CMD (MVO on CMR) increases long-term adverse risks x4 📈

4.    SCMR Case-of-the-Week #COTW gets its #SoMe game on 🧳🧲🤳

5.    SCMR Case-of-the-Week 2020 collection published—check it out 🧳🧲📢

6.    AI-based biventricular function from CMR. Still need humans? 🤖🤯😎

7.    Hybrid CMR/PET for active vs. chronic cardiac sarcoid ❤️💙

8.   What you need to know about CMR for patients with COVID-19 😷🧲🦠

9.   Validation vs. biopsy for updated Lake Louise CMR myocarditis criteria 🎯✅

10.  COPD associated with myocardial fibrosis & inflammation 🌬️💔

11.  Cardiac metastatic melanoma: Charcoal heart 🖤

On 21 July 2021, experts Chiara Bucciarelli-Ducci, MD, and Colin Berry, MD, presented the Siemens Healthineers webinar Novel Insights into MINOCA and INOCA: Resolving Diagnostic Dilemmas and discussed the potential of diagnostic imaging for risk assessment and prognosis in MINOCA and INOCA patients. This webinar highlighted the added value of CMR, CT, and Angio imaging in both acute and chronic ischemia without obstructive coronary arteries. The recording of this innovative session is now available on the SCMR Online Learning Portal.

Figure. T2w STIR basal short axis images; slice selection IR thickness A) 400% B) 200%

1. Zhu Y, Yang D, Zou L, Chen Y, Liu X, Chung YC. T2STIR preparation for single-shot cardiovascular magnetic resonance myocardial edema imaging. J Cardiovasc Magn Reson. 2019;21(1):72. Published 2019 Nov 21. doi:10.1186/s12968-019-0583-y      

The SCMR 2020 Case of the Week series was published in the Journal of Cardiovascular Magnetic Resonance on 11 October 2021. This open-access digital archive provides a means of further enhancing the education of those interested in CMR and a means of more readily identifying these cases using PubMed or a similar search engine.

The SCMR Case of the Week editors would like to thank their wonderful team of associate editors and reviewers. Please continue to submit your best illustrative cases and enjoy the 2020 series!

Left: 4D Flow 3D rendering. A labeled still-frame outlining the right atria (RA) and left (LA) atria, and right (RV) and left (LV) ventricles. The location of the unroofed coronary sinus is shown as a dotted line with an arrow demonstrating the direction of the shunt flow near the OS of the coronary sinus. From Case 20-01: Diagnosis of a coronary sinus atrial septal defect by 4D flow MRI. Jason G. Mandell, MD, MS; Adam Christopher, MD; Laura J. Olivieri, MD; Yue-Hin Loke, MD; Division of cardiology, Children's National Hospital, Washington, DC, USA.

Right: Still frame 3D reconstruction of aortic arch. Right sided aortic arch with a left descending aorta (DAo) and aberrant left subclavian artery (LSCA). AAO ascending aorta, LCCA left common carotid artery, RCCA right common carotid artery, RSCA right subclavian artery. From Case 20-04: It's Not ARVD! Afiachukwu Onuegbu, MD; Jina Chung, MD; Division of Cardiology, Harbor UCLA Medical Center.

The SCMR web site hosts “Case of the Week”—a case series designed to present case reports demonstrating the unique attributes of CMR in the diagnosis or management of cardiovascular disease. Each clinical presentation is followed by a brief discussion of the disease and unique role of CMR in disease diagnosis or management guidance. By nature, some of these are somewhat esoteric, but all are instructive. Recently we have published the case archive from 2020 in JCMR as a means of further enhancing the education of those interested in CMR and as a means of archiving this incredible resource from our members on PubMed. 

Last month's CMR Picture Puzzle answer:

Please use this link for a filtered PubMed list of all CMR-related manuscripts for October 2021—more than 350 in total!