When should we use contrast material in cardiac MRI?

At present, most of the cardiac magnetic resonance imaging (MRI) examinations rely on contrast‐enhanced protocols, but noncontrast alternatives are emerging. Late gadolinium enhancement (LGE) imaging for the detection of myocardial scar can be considered the main cause for the embedding of cardiac MRI into the clinical routine. The novel noncontrast technique of native T 1 mapping shows promise for tissue characterization in ischemic and nonischemic cardiomyopathy and may provide additional information over conventional LGE imaging. Technical issues, including measurements variability, still need to be resolved to facilitate a wide clinical application. Ischemia detection can be performed with contrast‐based stress perfusion and contrast‐free stress wall motion imaging. For coronary magnetic resonance angiography (MRA), protocols with and without contrast material have been developed. Research on coronary atherosclerotic plaque characterization has introduced new applications of contrast material. For MRA of the aorta, which traditionally relied on contrast administration, several noncontrast protocols have become available. This review provides an overview of when to use contrast material in cardiac and cardiac‐related vascular MRI, summarizes the major imaging building blocks, and describes the diagnostic value of the available contrast‐enhanced and noncontrast techniques. Contrast material in cardiac MRI should be used for LGE imaging for tissue characterization in ischemic or nonischemic cardiomyopathy and may be used for stress perfusion imaging for the detection of ischemia. In cardiac‐related vascular MRI, use of contrast material should be avoided, unless high‐quality angiography is required that cannot be obtained with noncontrast protocols. Level of Evidence: 5 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2017;46:1551–1572.