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Background Coronary angiography and the extent of coronary luminal stenosis has historically been the main factor used in guiding decisions regarding revascularisation in patients with stable coronary artery disease. More recently, revascularisation based on invasive fractional flow reserve (FFR) measurements has been shown to result in a significant benefit for event free survival. Cardiac magnetic resonance (CMR) perfusion imaging has been shown to be superior to nuclear perfusion imaging and has the potential to become the non-invasive test of choice. Methods The MR-INFORM study is a prospective, multi-centre, randomized controlled, non-inferiority, outcome trial. It will compare the efficacy of the two investigative strategies for the management of patients with suspected coronary artery disease. Patients presenting with stable angina are randomized into two groups: The FFRINFORMED and the MR-INFORMED group (Figure 1). All patients undergo CMR perfusion scanning at 1.5T (various vendors) at baseline. The patients in the MRINFORMED arm of the trial will have their subsequent management based on the results of the CMR scan. Those patients with significant ischaemia will have coronary angiography and revascularisation guided by the results of the MR scan i.e stenting in arteries that demonstrate ischaemia . All patients with non-significant ischaemia will have medical therapy optimized. The baseline scan in the FFR-INFORMED arm will remain blinded and the patient will go on to have coronary angiography with FFR measurement in those arteries with a stenosis of 40 - 99%. The revascularisation decision in this group will be based on an FFR<0.8 below which a stenosis is physiologically significant. All patients will have a cardiovascular risk assessment at

Design and rationale of the MR-INFORM study: stress perfusion MRI to guide the management of patients with stable coronary artery disease