[Multimodality imaging in heart failure: phenotyping and clinical decision-making]

Heart failure (HF) is a global health priority traditionally managed based on ejection fraction (EF). However, EF is now recognized as insufficient to represent the pathophysiological complexity and clinical heterogeneity of the syndrome. Modern diagnostics have shifted toward multimodality imaging, acting as an integrated platform for phenotyping. Transthoracic echocardiography remains the first-line tool, evolving into a multiparametric approach that includes global longitudinal strain, right ventricular-arterial coupling assessment, and congestion monitoring via lung ultrasound and venous excess ultrasound. Cardiac magnetic resonance is the gold standard for tissue characterization, which is crucial for etiological definition and arrhythmic risk stratification through fibrosis identification (late gadolinium enhancement). Cardiac computed tomography is essential for coronary anatomy evaluation and procedural planning, while nuclear imaging (single-photon emission computed tomography/positron emission tomography) provides unique insights into metabolism, inflammation, and sympathetic innervation. Integrating these modalities, guided by clinical questions, enables personalized therapeutic management, tracking of disease trajectories (such as improved HF), and optimization of clinical decision-making.