Seeing and sensing the heart: integrating non-coding RNA biomarkers with imaging in cardiovascular medicine

Non-coding RNA (ncRNA), including microRNA, long non-coding RNA, and circular RNA, are epigenetic signals acting as upstream regulators in several cardiovascular disease processes. This review explores how ncRNA profiling complements non-invasive cardiac imaging modalities by providing biological insights into structural and functional phenotypes. In conditions such as hypertensive heart disease and aortic stenosis, ncRNAs like microRNA (miR)-29 and miR-155 correlate with left ventricular hypertrophy and fibrosis. In dilated cardiomyopathy and heart failure, circulating miR-150-5p, miR-21, and LIPCAR associate with disease severity and prognosis beyond well-established echocardiographic prognosticators. Post-infarction remodelling has been linked to dynamic changes in miR-155, miR-143, and miR-150, while atrial disease and atrial fibrillation progression are reflected in distinct miRNA profiles. In valve disease, miR-206 levels mirror functional recovery after transcatheter aortic valve implantation, while they associate with right-ventricular dysfunction in the setting of pulmonary hypertension. Cardiac MRI studies have shown that ncRNA such as miR-29a and has-Chr8:96 may distinguish pathologies including hypertrophic cardiomyopathy and myocarditis. In nuclear imaging, circ-MBOAT2 and miR-495 correlate with myocardial perfusion in chronic total occlusion, and exosomal miRNA may support functional stratification. CT imaging may also benefit from ncRNA biomarkers such as miR-3154 in vascular disease. Despite promises, standardization and prospective validation remain crucial for clinical translation. Taken together, ncRNA enrich imaging phenotypes by illuminating molecular underpinnings, enhancing prognostication, and offering potential targets for personalized cardiovascular care.