Cardiac magnetic resonance in ischemic cardiomyopathy: from tissue characterization to prognostic stratification

Abstract

Ischemic cardiomyopathy (ICM), the most prevalent cause of heart failure globally, remains a significant contributor to cardiovascular morbidity and mortality. Despite advances in medical and interventional therapies, outcomes for patients with ICM remain suboptimal, underscoring the need for accurate diagnostic tools and effective risk stratification. Cardiac magnetic resonance imaging (CMR) has emerged as a powerful, non-invasive modality that provides detailed anatomical, functional, and tissue-level insights essential for managing this complex condition. A literature search was performed using PubMed, Embase, and the Cochrane Library to identify relevant studies published between January 2005 and January 2026. Search terms included combinations of “cardiac magnetic resonance,” “ischemic cardiomyopathy,” “late gadolinium enhancement,” “stress perfusion CMR,” “myocardial viability,” “prognosis,” and “revascularization.” Randomized controlled trials, cohort studies, systematic reviews, meta-analyses, and major society guidelines evaluating CMR in adult patients with suspected or established ischemic cardiomyopathy were included. This review explores the comprehensive role of CMR in the diagnosis, differentiation, and prognostication of ICM. It highlights CMR’s superiority in quantifying ventricular function and detecting myocardial ischemia using routine cine and perfusion sequences, while also emphasizing the emerging role of CMR speckle tracking—referred to as feature tracking (CMR-FT)—in the detection of ischemia and the assessment of myocardial viability. The review further evaluates the role of CMR in distinguishing ischemic from non-ischemic cardiomyopathies through advanced tissue characterization techniques, including parametric mapping and late gadolinium enhancement (LGE). Additionally, it discusses CMR’s utility in guiding revascularization decisions and predicting clinical outcomes based on scar burden and myocardial viability. Although certain limitations remain, such as accessibility and patient compatibility, CMR continues to represent the standard for non-invasive cardiac imaging in ICM, providing clinicians with critical information across all stages of patient care, however, the expanding applications of CMR must be interpreted within evolving evidence and guideline recommendations rather than generalized superiority claims.