Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease 2 - CE-MARC 2

Contribution To Literature:

The CE-MARC 2 trial showed that CMR was superior to NICE guideline-directed care.


The goal of the trial was to evaluate three treatment strategies among patients with suspected coronary heart disease (CHD), including: 1) cardiac magnetic resonance (CMR)-guided care, 2) myocardial perfusion scintigraphy (MPS)-guided care, and 3) National Institute for Health and Care Excellence (NICE) guideline-directed care.

Study Design

  • Randomized
  • Parallel

Patients with suspected CHD were randomized to CMR-guided care (n = 481) versus MPS-guided care (n = 481) versus NICE guideline-directed care (n = 240).

  • Total number of enrollees: 1,202
  • Duration of follow-up: 12 months
  • Mean patient age: 56 years
  • Percentage female: 47%
  • Percentage diabetics: 13%

Inclusion criteria:

  • Patients with suspected angina at least 30 years of age
  • Pretest probability of CHD 10-90%
  • Suitable for revascularization

Exclusion criteria:

  • Nonangina chest pain
  • Normal MPS or cardiac computed tomography within the previous 2 years
  • Clinically unstable
  • Previous myocardial infarction, coronary revascularization, or contraindication to any study noninvasive imaging test

Principal Findings:

The primary outcome, incidence of unnecessary invasive angiography, occurred in 7.5% of the CMR group vs. 7.1% of the MPS group vs. 28.8% of the NICE guideline-directed care group (CMR vs. NICE, p value < 0.001; CMR vs. MPS, p value = 0.32).

Secondary outcomes, major adverse cardiac events (MACE) at 12 months, occurred in 2.5% of the CMR group vs. 2.5% of the MPS group vs. 1.7% of the NICE guideline-directed care group (CMR vs. NICE, p value = NS; CMR vs. MPS, p value = NS).


Among patients with suspected CHD, CMR-guided care resulted in a lower frequency of unnecessary invasive angiography versus NICE guideline-directed care. Unnecessary angiography was similar between CMR- and MPS-guided care. MACE was similar between groups.


Greenwood JP, Ripley DP, Berry C, et al., on behalf of the CE-MARC 2 Investigators. Effect of Care Guided by Cardiovascular Magnetic Resonance, Myocardial Perfusion Scintigraphy, or NICE Guidelines on Subsequent Unnecessary Angiography Rates: The CE-MARC 2 Randomized Clinical Trial. JAMA 2016;Aug 29:[Epub ahead of print].

Presented by Dr. John Greenwood at the European Society of Cardiology Congress, Rome, Italy, August 29, 2016.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Stable Ischemic Heart Disease, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Magnetic Resonance Imaging, Nuclear Imaging, Chronic Angina

Keywords: Angina, Stable, Angiography, Chest Pain, Coronary Artery Disease, Magnetic Resonance Imaging, Magnetic Resonance Spectroscopy, Myocardial Perfusion Imaging, ESC Congress

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