Cardiac amyloidosis: the role of multimodality imaging

Abstract Cardiac amyloidosis is an increasingly recognized cause of heart failure, driven by advances in diagnostic techniques and the emergence of disease-modifying therapies. Early and accurate diagnosis is essential as timely treatment influences prognosis. Although endomyocardial biopsy remains the reference standard, non-invasive imaging has become central to the diagnostic pathway and disease evaluation. This review summarizes the contemporary role of multimodality imaging in cardiac amyloidosis. Echocardiography remains the first-line imaging modality and can provide important diagnostic clues, including increased ventricular wall thickness and apical sparing on strain analyses. CMR enables detailed tissue characterization, allowing non-invasive assessment of myocardial amyloid burden and disease progression. Bone scintigraphy has revolutionized the diagnosis of transthyretin amyloid cardiomyopathy by enabling a reliable non-biopsy diagnosis after exclusion of light-chain amyloidosis. Emerging PET tracers may further improve early detection, quantification of amyloid burden, and monitoring of treatment response. The integration of multimodality imaging has fundamentally changed the diagnostic and therapeutic landscape of cardiac amyloidosis, facilitating earlier recognition, improved risk stratification, and longitudinal disease monitoring. As novel therapies continue to emerge, advanced imaging techniques are expected to play an increasingly important role in personalized management and evaluation of therapeutic response.