Subclinical Cardiac Remodeling in Borderline Hypertension: The Role of Advanced Imaging

Among modifiable risk factors for cardiovascular diseases, hypertension is the most common. The most common form of cardiac damage in hypertensive patients is left ventricular hypertrophy (LVH), which is far from being the earliest and most sensitive marker of cardiac involvement. Microvascular dysfunction, impaired myocardial deformation, interstitial fibrosis, and neurohormonal activation are only some of the functional and structural elements that might not be detected by basic investigations such as electrocardiography and echocardiography, since they usually develop years before LVH. With this narrative review, we intend to highlight the role of advanced cardiac imaging in early, subclinical cardiac remodeling and (pre)hypertension. We delineated the concept of early cardiac remodeling, reviewed the limits of conventional LVH detection, and discussed the diagnostic and prognostic value of speckle-tracking echocardiography with global longitudinal strain (GLS) and of cardiac magnetic resonance with late gadolinium enhancement, T1 mapping, and extracellular volume (ECV) quantification. Left ventricular ejection fraction impairment occurs later than GLS decline, whereas T1 mapping and ECV allow for interstitial fibrosis detection at the tissue level. Novel strain methods, circulating biomarkers, and artificial intelligence are embraced as complementary tools for earlier detection and risk stratification. The review was based on a non-systematic search of the PubMed and Scopus databases for records through April 2026, ultimately including 56 references. The experience of advanced imaging techniques can identify subclinical myocardial alterations far earlier than conventional investigations; thus, they should be considered as potential complementary methods and not alternatives.