Cardiac MRI in diabetic cardiomyopathy: translating imaging biomarkers into clinical practice

Diabetic cardiomyopathy (DbCM) is a progressive cardiac disorder characterized by left ventricular dysfunction in the presence of diabetes mellitus. With the rising global prevalence of diabetes, early detection and intervention are crucial to prevent transition to overt heart failure. Cardiac magnetic resonance (CMR) has emerged as a powerful non-invasive imaging modality, providing comprehensive insights into myocardial structure, function, and tissue characteristics. This review highlights the role of multiparametric CMR, including T1 mapping, late gadolinium enhancement, strain analysis, perfusion imaging, and spectroscopy, in identifying key pathological features of DbCM such as diffuse fibrosis, microvascular dysfunction, steatosis, and subclinical systolic/diastolic impairment. Furthermore, we discuss how these imaging biomarkers can stratify risk, monitor disease progression, and evaluate treatment efficacy, particularly in the context of comorbidities and emerging therapies such as sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists. Future directions include the integration of artificial intelligence for automated analysis and the development of molecular imaging probes for targeted detection of early disease pathways. CMR holds significant promise for translating advanced imaging biomarkers into clinical practice, enabling personalized management of DbCM.