Optimizing imaging techniques in hypertrophic cardiomyopathy: challenges and opportunities

Imaging is fundamental to the evaluation and management of hypertrophic cardiomyopathy, yet substantial variability in acquisition, analysis, and interpretation persists across modalities. These methodological inconsistencies limit reproducibility, hinder multimodality integration, and complicate the use of imaging findings in clinical decision-making. This review examines key technical challenges and optimization strategies across contemporary imaging modalities used in HCM. We discuss practical considerations in echocardiography for assessing dynamic left ventricular outflow tract obstruction and mitral valve mechanisms; methodological uncertainties in cardiac magnetic resonance (CMR), including fibrosis quantification, parametric mapping, and perfusion imaging; evolving applications of computed tomography (CT) for detailed anatomic assessment, coronary evaluation, and procedural planning; and the selective role of nuclear imaging for quantifying microvascular dysfunction and evaluating phenocopies. Emphasis is placed on sources of measurement variability, current limitations, and opportunities for standardization and automation. We further highlight the importance of integrating multimodality imaging within tailored clinical workflows with complementary, rather than sequential use of imaging techniques. Optimizing imaging methodology is essential to translating technical advances into consistent and meaningful improvements in the care for patients with HCM.