Multimodality imaging in hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is a myocardial disorder characterized by unexplained myocardial hypertrophy. Although the diagnosis of HCM is traditionally based on increased left ventricular (LV) wall thickness, contemporary management requires a comprehensive multimodality imaging approach to accurately define disease phenotype, assess functional consequences, and guide risk stratification. Transthoracic echocardiography remains the first-line imaging modality, providing real-time evaluation of LV morphology, systolic and diastolic function, and LV outflow tract obstruction (LVOTO). However, its ability to assess myocardial tissue characteristics and complex morphologic variants may be limited in selected patients. Cardiac magnetic resonance (CMR) offers superior spatial resolution and allows detection of myocardial fibrosis using late gadolinium enhancement. Cardiac computed tomography serves as a complementary tool for evaluating coronary artery anatomy and detailed cardiac structure, particularly in patients with suboptimal echocardiographic windows or contraindications to CMR. This review summarizes the strengths and limitations of each imaging modality and highlights their complementary roles in the evaluation of cardiac morphology, systolic and diastolic function, LVOTO, and tissue characterization. An integrated imaging strategy is essential for optimized diagnosis, individualized risk stratification, and informed therapeutic decision-making in patients with HCM.