In a 33‑year‑old patient with chest pain and a stress echocardiogram showing mildly reduced left ventricular ejection fraction (51%) but normal wall‑motion response, no inducible ischemia, and excellent functional capacity (15 metabolic equivalents), should a cardiac magnetic resonance (CMR) be performed to further evaluate the ejection fraction?

Cardiac MRI is Not Indicated in This Patient

In this 33-year-old with mildly reduced ejection fraction (51%) but excellent functional capacity, normal wall motion, no inducible ischemia, and a low-risk Duke Treadmill Score, cardiac MRI is not warranted for further EF evaluation. The stress echocardiogram has already provided comprehensive prognostic information that supersedes the borderline EF finding.

Rationale Based on Current Evidence

The Stress Echo Results Are Reassuring and Sufficient

• Your patient achieved 15 metabolic equivalents (METs) with 97% of maximum predicted heart rate, which represents excellent functional capacity that strongly predicts low cardiovascular risk 1
• Individuals exercising >10 metabolic equivalents with negative stress imaging have excellent prognosis and do not require additional testing 1
• The Duke Treadmill Score of 9 indicates low risk, with normal augmentation of all wall segments and no evidence of ischemia 1
• The mild chest pain during exercise without ECG changes or wall motion abnormalities suggests a non-ischemic etiology 1

The EF of 51% Does Not Meet Criteria for Advanced Imaging

• An ejection fraction of 51% is only mildly reduced and does not represent significant left ventricular systolic dysfunction 1
• Guidelines recommend echocardiography as the primary modality for assessing LV function, with CMR or radionuclide imaging reserved for cases where echocardiography is suboptimal or provides inadequate information 1
• Your stress echo provided high-quality images with successful biplane method of discs measurement, indicating adequate acoustic windows 1
• CMR is indicated when echocardiographic assessment of LV function is "suboptimal" or there is "discordance between clinical findings and echocardiography" - neither applies here 1

No Clinical Indication for Tissue Characterization

• CMR tissue characterization (late gadolinium enhancement) is valuable when there is unexplained LV dysfunction, suspicion for infiltrative disease, myocarditis, or sarcoidosis 2, 3, 4
• Your patient has normal wall motion at rest and with stress, making structural myocardial disease (fibrosis, infiltration, prior infarction) highly unlikely 2
• The excellent exercise capacity and absence of ischemia argue strongly against significant myocardial damage that would be detected by late gadolinium enhancement 2

What This Patient Actually Needs

Focus on the Chest Pain Etiology

• The mild chest pain with exercise in the absence of ischemia, ECG changes, or wall motion abnormalities suggests non-cardiac causes (musculoskeletal, gastroesophageal, anxiety) 1
• Consider alternative diagnoses including costochondritis, gastroesophageal reflux disease, or anxiety-related symptoms in this young patient 1

Optimize Cardiovascular Risk Factor Management

• Assess and address traditional cardiovascular risk factors including hypertension, diabetes, dyslipidemia, smoking, and family history 1
• The mildly reduced EF may normalize with risk factor modification and does not require immediate intervention at this level with preserved functional capacity 1

Serial Echocardiographic Follow-Up is Appropriate

• Repeat echocardiography in 6-12 months to reassess EF and ensure stability, particularly if the patient remains asymptomatic 1
• If EF declines further or symptoms develop, then consider CMR for tissue characterization to identify reversible causes 1

Common Pitfalls to Avoid

• Do not over-investigate borderline findings in asymptomatic patients with excellent functional capacity - the stress test performance is the most powerful prognostic indicator here 1
• Do not confuse "mildly reduced" EF (51%) with clinically significant systolic dysfunction - this level does not trigger guideline-directed medical therapy for heart failure 1
• Do not order CMR reflexively for every EF <55% - reserve it for cases where the result will change management or when there is unexplained dysfunction despite adequate stress testing 1