Multimodality Imaging in Hypertrophic Cardiomyopathy: From Phenotyping to Precision Clinical Management.

Hypertrophic cardiomyopathy (HCM) is a genetically and phenotypically heterogeneous myocardial disease characterized by unexplained left ventricular hypertrophy and a broad spectrum of clinical manifestations, ranging from an asymptomatic phenotype to heart failure, atrial and ventricular arrhythmias, sudden cardiac death, and advanced heart failure. Accurate diagnosis and risk stratification therefore require complex assessment. Multimodality cardiovascular imaging provides complementary structural, functional, and tissue characterization that cannot be obtained using a single imaging technique. Transthoracic echocardiography remains the cornerstone of initial diagnosis, hemodynamic assessment, and longitudinal follow-up, while advanced echocardiographic techniques provide additional information regarding myocardial and left atrial mechanics. Cardiac magnetic resonance (CMR) has become central to phenotypic characterization and tissue assessment. Cardiac computed tomography offers complementary high-resolution anatomical information, particularly for coronary assessment and procedural planning, whereas nuclear imaging, provides insights into coronary microvascular dysfunction, myocardial perfusion, and selected phenocopies such as transthyretin cardiac amyloidosis. Multimodality imaging also facilitates differentiation of HCM from other conditions such as athlete's heart, hypertensive heart disease, and infiltrative cardiomyopathies. Integration of imaging biomarkers with clinical and genetic information may improve prediction of adverse outcomes. Thus, multimodality imaging should be regarded not as a collection of competing techniques but as an integrated framework for precision diagnosis, risk stratification, therapeutic planning, and longitudinal management of patients with HCM.