<![CDATA[Background: Evaluating chronic chest pain in elderly, multimorbid patients with limited mobility is a common clinical challenge. Conventional treadmill stress testing is often not feasible, necessitating alternative diagnostic strategies. While guidelines recommend non-invasive imaging, data on the utility of stress cardiac magnetic resonance imaging (CMR) in this specific, growing demographic remain limited. Case Presentation: A 77-year-old male with a complex history of coronary artery disease (status post percutaneous coronary intervention in 2007 and 2016), osteoarthritis, geriatric syndrome, and multiple cardiovascular risk factors presented with recurrent chest pain despite optimal medical therapy. His significant mobility limitations due to osteoarthritis precluded exercise stress testing. Methods: A comprehensive diagnostic workup was performed. This included laboratory studies, echocardiography, and 24-hour Holter monitoring. Given the contraindication to treadmill testing, a multiparametric stress CMR was conducted, incorporating adenosine stress/rest perfusion, late gadolinium enhancement (LGE), and parametric mapping (T1, T2) to comprehensively assess for ischemia, scar, and tissue pathology. Results: Echocardiography showed preserved left ventricular systolic function (EF 73%). Stress CMR definitively excluded inducible ischemia, with normal stress perfusion and no evidence of myocardial fibrosis or scar on LGE. Biventricular size and function were normal. Holter monitoring revealed a sinus rhythm with a significant burden of infrequent premature ventricular contractions (PVCs) (4.8%, highest grade: couplets), but no sustained arrhythmias or ischemic ST-segment changes. Based on these findings, the chest pain was attributed to non-cardiac causes or PVC-related symptoms, rather than active coronary ischemia. Conclusion: This case demonstrates the critical diagnostic value of multiparametric stress CMR in elderly, multimorbid patients with chest pain who are unsuitable for exercise stress testing. It safely and effectively ruled out significant obstructive coronary disease, thereby avoiding unnecessary invasive procedures and guiding management towards arrhythmia monitoring and medication optimization. Stress CMR should be considered a first-line non-invasive modality in this vulnerable population to enable accurate diagnosis and personalized care.]]>
