AbstractNoninvasive cardiac magnetic resonance (CMR) imaging has progressed rapidly over the past few years and will most likely become an integral part of the diagnostic workup of patients with known or suspected coronary artery disease (CAD). In this article the rationale for using perfusion‐CMR is discussed, followed by a summary of current state‐of‐the‐art perfusion‐CMR techniques that addresses pharmacological stress, monitoring, pulse sequences, and doses of contrast media (CM) for first‐pass studies. In the second part, unresolved aspects of perfusion‐CMR, such as the lack of fully established and validated imaging protocols, are discussed. The optimum pulse sequence parameters, required cardiac coverage, analysis algorithms, criteria for data quality, and other aspects remain to be defined. Furthermore, since expertise in perfusion‐CMR is not yet widely available, training of physicians and technicians to perform perfusion‐CMR according to recognized standards is an important future requirement. In the last part of the review, some ideas are proposed to improve the management of patients with known or suspected CAD. This involves making a shift from a “reactive” strategy, in which patients are typically approached when they are symptomatic, to an “active” strategy, in which perfusion‐CMR is performed for early detection of high‐risk patients so that revascularizations can be performed before potentially deadly infarcts occur. An ideal test for such an active strategy would be highly accurate, reliable, safe (and thus repeatable), and affordable. Large multicenter trials have shown that in experienced centers perfusion‐CMR is reliable and repeatable, and it is hoped that future studies will demonstrate its cost‐effectiveness as well. J. Magn. Reson. Imaging 2006. © 2006 Wiley‐Liss, Inc.