Cardiac imaging in Chagas cardiomyopathy for phenotypic characterisation and risk stratification

Chagas disease, caused by Trypanosoma cruzi, remains one of the leading infectious causes of non-ischemic cardiomyopathy worldwide. Although an estimated 6-7 million individuals are chronically infected, 20-30% will develop Chagas cardiomyopathy (CCM), a progressive myocardial disease characterised by conduction abnormalities, ventricular arrhythmias, focal aneurysm formation, diffuse fibrosis, and heart failure. Cardiac involvement often evolves silently over decades, and conventional clinical markers frequently underestimate early myocardial injury. Advances in cardiac imaging have fundamentally reshaped the understanding of CCM, demonstrating that myocardial involvement frequently precedes symptoms and may occur despite normal electrocardiography. Contemporary modalities, including transthoracic echocardiography with deformation imaging and cardiac magnetic resonance, enable detailed characterisation of ventricular mechanics, myocardial fibrosis, inflammation, and perfusion abnormalities across disease stages. These techniques have revealed a distinctive, segmental pattern of myocardial injury and provided mechanistic insight into arrhythmogenesis and disease progression. This review synthesises current evidence on the natural history of Chagas disease, with a particular focus on the expanding role of multimodality cardiac imaging in the early detection, phenotypic characterisation, and risk stratification of CCM.