The Future of Imaging in Heart Failure: Toward Precision Phenotyping, Integration, and Intelligence

Heart failure (HF) is increasingly understood not as a single, uniformly treated diagnosis but as a heterogeneous syndrome requiring aetiological clarification, in which cardiac imaging is central. As the opening article of this journal's 'Imaging in Heart Failure' section, this review surveys the technologies currently reshaping HF imaging and sets out the section's scope and priorities, framing the shift from a descriptive, modality-siloed practice toward an integrated, predictive, patient-specific discipline.

Artificial intelligence (AI) now delivers expert-level echocardiography automation, guides image acquisition by novices in resource-limited settings, detects aetiologies such as transthyretin amyloid cardiomyopathy from a single acquisition and enables deep phenotyping through radiomics and vendor-agnostic strain analysis. Handheld, AI-enabled point-of-care ultrasound extends imaging-guided triage beyond the echocardiography laboratory. Cardiovascular magnetic resonance (CMR) advances - parametric mapping, four-dimensional flow, diffusion tensor imaging, spectroscopy, and accelerated reconstruction - broaden tissue and metabolic characterisation, including patients with implanted devices. Molecular imaging with novel positron emission tomography tracers and hyperpolarised magnetic resonance is moving from depicting the structural consequences of disease to imaging active pathobiology, while photon-counting computed tomography and image-derived digital twins support one-stop structural assessment and in-silico prediction of therapy response. The convergence of AI, molecular imaging and advanced precision is transforming HF imaging from better pictures into smarter, integrated, personalised data that directly inform care. Realising this promise will require rigorous validation, attention to algorithmic bias and generalisability, demonstrated cost-effectiveness, curricular reform, and equitable access. This section aims to critically appraise these innovations and their translation into practice.