Starvation ketoacidosis (SKA) represents one of three metabolic acidoses caused by the accumulation of ketone bodies within the bloodstream. While easily treated, it is a diagnosis that can be easily missed in patients with an unexplained metabolic acidosis. In this case report, we discuss two patients presenting with a starvation ketoacidosis and psychiatric illness. This link between SKA and psychiatric disease is especially pertinent as this is a cohort of patients who may not be able to give an accurate history, which can potentially lead to a delay in diagnosis and treatment. Furthermore, the patient cohort described here have higher rates of alcohol dependence and are therefore at risk of alcoholic ketoacidosis. It is important to recognise that these conditions may coexist and should be managed as such, with thiamine prior to carbohydrate replacement in all at-risk patients.

Aims: Cardiovascular magnetic resonance (CMR) has shifted from a problem‐solving modality to a foundational, first‐line test in European Society of Cardiology (ESC) guidance. This review synthesises how CMR is positioned within ESC guidelines (2015–2025) and allied EACVI/EHRA statements, emphasizing its decision‐shaping role through accurate biventricular volumetry, tissue characterization (late gadolinium enhancement [LGE], T1/T2 mapping, extracellular volume [ECV]), and flow quantification (phase‐contract, with emerging 4D‐flow). Methods: We performed a structured narrative review of adult ESC clinical practice guidelines and allied expert statements (January 2015–December 2025) containing explicit CMR recommendations. Documents were identified via society portals and PubMed, excluding pediatric guidance and non‐recommendation technical notes. Two independent reviewers extracted data on clinical context, CMR role, and recommendation Class/Level of Evidence, resolving discrepancies by consensus. Results: The search identified 13 ESC guidelines—spanning coronary syndromes, sports cardiology, cardio‐oncology, myocarditis, and valvular disease—and 13 supporting statements. The data demonstrate a progressive elevation of CMR to a strongly favored investigation (commonly Class I/IIa, Level B/C) in scenarios where precision imaging alters management. Allied expert statements standardize protocols, reference ranges, and quantification methods to facilitate consistent clinical implementation. Conclusion: ESC guidelines have repositioned CMR from a tool of last resort to a cornerstone of cardiovascular diagnostics. Its adjudicatory role leverages tissue characterization and quantification to resolve clinical scenarios with high diagnostic uncertainty, including MINOCA, suspected cardiomyopathy, sports participation after myocarditis, and complex valvular disease. Expert statements provide the practical framework for implementation, supporting the progressive integration of CMR into clinical pathways.

Right heart dysfunction increases morbidity and mortality in cardiovascular diseases. Four-dimensional flow cardiovascular magnetic resonance (4D flow CMR) imaging evaluates detailed right heart physiology, including vorticity, flow dynamics, kinetic energy (KE) and energy loss (EL). This systematic review synthesized literature using 4D flow CMR to assess right atrial (RA) and right ventricular (RV) hemodynamics in health and disease. A systematic search of the Scopus database (up to March 2025) identified observational studies investigating 4D flow CMR of right heart function in adults. Data on RA flow dynamics, RV flow components, KE, EL, and hemodynamic parameters were narratively synthesized. Quality assessment used the AXIS tool From 240 identified articles, 17 studies (894 participants) met eligibility criteria, including healthy individuals and patients with pulmonary hypertension (PH). RA flow dynamics, described in five studies, were characterized by a dominant vortex in health, interrupted with disease. RV flow components consistently showed a decline in direct flow and increased residual volume with disease. Atrial and ventricular KE assessments revealed age, sex, and disease-specific alterations, with rotational flow appearing to conserve right atrial KE. Increased EL was noted in PH. 4D flow CMR is a powerful tool for assessing novel right heart hemodynamic parameters. Quantifying flow patterns, components, and energetics provides a comprehensive overview of right heart function, promising to improve the diagnosis, management, and prognostic stratification of right heart diseases.

Aims: Aortic regurgitation (AR) is a prevalent valvular disease. Cardiovascular magnetic resonance (CMR) imaging is emerging as an accurate and precise method for assessing AR. However, its role in guiding interventions and risk stratification for outcomes remains to be fully defined. Objective: This systematic review and meta-analysis evaluate the predictive utility of CMR-derived AR fraction (ARF) in determining intervention timing and clinical outcomes. Methods and results: A systematic search identified observational studies assessing CMR-derived ARF in AR prognostication. Hazard ratios (HRs) for intervention timing, mortality, and heart failure were pooled using a random-effects model. Study heterogeneity (I² statistic) was assessed, and publication bias was evaluated using a funnel plot. A total of 1235 studies were screened, with 12 meeting the inclusion criteria. Eight studies (n = 1996 patients) were included in the meta-analysis. ARF severity thresholds ranged from 30 to 43% (mean 33.7%). Follow-up ranged from 2 to 5.1 years. The pooled HR for clinic outcomes with an ARF > 33% was 4.12 (95% CI: 2.31–7.34, P value < 0.01). The highest reported HR was 24.59, while the lowest was 1.04. Studies demonstrated that a higher ARF correlates with an increased risk of adverse outcomes, supporting CMR as a key tool for risk stratification and intervention timing. Conclusion: CMR-derived ARF is strongly predictive of clinical outcomes. ARF > 33% is associated with significantly increased risk, warranting its integration into clinical decision-making frameworks.

Background and Objectives: Coronary sinus oxygen saturation is a useful indicator of health and disease states. However, it is not routinely used in clinical practice. Cardiovascular magnetic resonance imaging (CMR) oximetry can accurately estimate oxygen saturation in the pulmonary artery. This research aimed to provide a method for calculating coronary sinus oxygen saturation (ScsO₂) from pulmonary artery oxygen saturation (SpaO₂) that could be applied to CMR. Materials and Methods: A systematic literature review was conducted to identify prior work that included invasive measures of ScsO₂ and either SpaO₂ or right ventricular oxygen saturation. This revealed one study with appropriate data (ScsO₂ and SpaO₂ measurements, n = 18). We then carried out agreement and correlation analyses. Results: Regression analysis demonstrated a statistically significant, positive relationship between ScsO₂ and SpaO₂, giving a regression equation of ScsO₂ = −31.198 + 1.062 × SpaO₂ (r = 0.76, p < 0.001). A multivariable regression analysis of all reported variables, excluding SpaO₂, independently identified superior vena cava oxygen saturation (SsvcO₂) and arterial oxygen saturation (SaO₂) as predictors of ScsO₂ (r = 0.78, p < 0.001), deriving the equation ScsO₂ = −452.8345 + 4.3579 × SaO₂ + 0.8537 × SsvcO₂. Conclusions: In this study, we demonstrated a correlation between coronary sinus oxygen saturation and pulmonary artery oxygen saturation, allowing the estimation of ScsO₂ from SpaO₂. This association enables the estimation of ScsO₂ from purely CMR-derived data. We have also described a second model using arterial and superior vena cava saturation measurements, providing an alternative method. Future validation in larger, independent cohorts is needed.