🫀 ESC Heart Failure Guidelines 2026: Cardiac Imaging — Beyond LVEF: a major shift in cardiac imaging 👉 Don’t just measure EF — identify the phenotype & cause of HF. Here are the 🔑 imaging takeaways: 🔹 Echo remains first-line TTE remains the cornerstone of HF assessment, providing information on: • LVEF & LV remodelling • RV function • diastolic function/filling pressures • valvular disease • pulmonary pressures • haemodynamic consequences of HF The message is clear: a HF echo should be much more than an EF measurement. 🔹 CMR: define the myocardial substrate CMR is particularly valuable when echo is inadequate or the aetiology of HF/cardiomyopathy remains uncertain. LGE and parametric mapping can identify: ➡️ scar/fibrosis ➡️ inflammation ➡️ infiltration ➡️ iron overload ➡️ characteristic cardiomyopathy patterns This is particularly relevant in suspected myocarditis, amyloidosis, sarcoidosis & other cardiomyopathies. 🔹 CT/CTCA: answer the coronary/anatomical question CT coronary angiography can help define or exclude CAD in appropriately selected patients. When ischaemia rather than coronary anatomy is the question, stress echo, stress CMR, SPECT or PET may be appropriate. 🔹 Amyloidosis: imaging can establish the diagnosis For suspected ATTR cardiac amyloidosis, evaluation integrates: ☢️ bone-tracer scintigraphy 🧪 serum/urine immunofixation + free light chains 🧲 CMR when appropriate Identifying ATTR-CM is increasingly important given the expanding availability of disease-modifying therapies. 🔹 Cardiac sarcoidosis FDG-PET should be considered when cardiac sarcoidosis is suspected. CMR and PET provide complementary information: 🧲 CMR → myocardial injury/scar ☢️ FDG-PET → active inflammation 🔹 HFpEF does not mean normal function Imaging should look beyond LVEF & assess: ➡️ diastolic dysfunction ➡️ LA remodelling ➡️ LV hypertrophy ➡️ filling pressures ➡️ pulmonary pressures ➡️ RV function When resting investigations are inconclusive, exercise testing &/or invasive haemodynamic assessment may be needed. 🔹 Imaging before CRT/ICD LV function should be reassessed after appropriate foundational therapy when the result will determine device eligibility. For CRT, imaging must be integrated with the electrical phenotype. ⚡ CRT remains Class I, LoE A in appropriately selected symptomatic HFrEF patients with: • LVEF ≤35% • sinus rhythm • LBBB • QRS ≥150 ms • despite optimal foundational therapy 🔹 2ndry MR →imaging guides intervention Echo defines MR severity, mechanism, LV/RV function & suitability for intervention. In appropriately selected symptomatic HFrEF + severe 2ndry MR despite optimized therapy ± CRT, mitral TEER now carries a Class I recommendation to ⬇️HF hospitalization & improve QoL. 🔹 Advanced HF: haemodynamics matter In patients being evaluated for transplantation or durable mechanical circulatory support: ➡️ Right-heart cath— Class I, LoE C This provides critical information on filling pressures, cardiac output and pulmonary vascular haemodynamics. 📌 The 2026 take-home message Cardiac imaging in HF is moving from EF → phenotype &→ haemodynamics→ tissue characterization→ aetiology →targeted treatment 💡 Echo tells us how the heart is functioning. CMR tells us about the myocardium. CT defines anatomy. Nuclear imaging identifies specific disease processes. Haemodynamics completes the picture when non-invasive imaging is insufficient. The key question is no longer simply: “What is the EF?” It is: 👉 “Why does this patient have HF— and will additional imaging change management?”