Yu ZHANG, Sung Min KO
Diagnostic and Interventional Radiology - 2026;32(4):426-436
Myocardial infarction (MI) is a leading cause of morbidity and mortality worldwide. Although rapid diagnosis and reperfusion in the acute setting rely primarily on clinical assessment, electrocardiography, echocardiography, and invasive coronary angiography, advanced cardiac imaging plays an essential role beyond the hyperacute phase. Cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR) imaging provide complementary information that extends from coronary anatomy to myocardial tissue characterization and functional assessment. CMR imaging enables the comprehensive, multiparametric evaluation of MI, including left ventricular function, myocardial edema and area at risk, infarct size and transmural extent, microvascular obstruction, intramyocardial hemorrhage, myocardial viability, and ischemia using cine imaging, T1/T2 and T2* mapping, perfusion imaging, and late gadolinium enhancement. These features support an accurate differentiation between acute and chronic infarction, an assessment of myocardial salvage, and prognostic stratification. CCT offers a rapid, non-invasive assessment of coronary artery stenosis and plaque characteristics and has expanded to include an evaluation of ventricular function, myocardial perfusion, and delayed-enhancement patterns. When combined with CT-derived fractional flow reserve or myocardial perfusion imaging, CT allows for an integrated anatomic and functional assessment of the myocardium, particularly for non-culprit lesions, following MI. Myocardial delayed-enhancement CT can visualize the infarcted myocardium and microvascular injury in select patients, though it remains complementary to magnetic resonance imaging. This pictorial essay illustrates the imaging spectrum of MI and its major mechanical and thromboembolic complications, including ventricular rupture, septal defects, papillary muscle rupture, aneurysm formation, left ventricular thrombi, and pericardial disease. By highlighting the strengths and limitations of CCT and CMR and providing practical guidance for modality selection, this article aims to support informed clinical decision-making in the contemporary management of patients with MI.
