Multimodality imaging in cardiac amyloidosis: When and how to combine nuclear techniques with echocardiography and cardiac magnetic resonance imaging

Echocardiography and cardiac magnetic resonance (CMR) can demonstrate features of myocardial infiltration in cardiac amyloidosis, but cannot independently establish a definitive diagnosis or determine amyloid subtype. Accurate diagnosis requires integration of imaging with clinical assessment, laboratory testing for monoclonal gammopathy, radionuclide scintigraphy, and tissue biopsy when indicated. Echocardiography remains the first-line modality, identifying characteristic structural and functional abnormalities and offering prognostic information, with emerging innovations such as artificial intelligence showing promise for earlier detection. CMR adds high-resolution tissue characterization through late gadolinium enhancement, T1 mapping, and extracellular volume quantification, enabling early detection, disease staging, and longitudinal monitoring. computed tomography (CT)-derived extracellular volume provides a practical alternative when CMR is unavailable and may be incorporated opportunistically during routine cardiac CT studies. Integrating these modalities within contemporary diagnostic pathways allows tailored sequencing based on clinical context, improving diagnostic accuracy and guiding decisions regarding radionuclide imaging and biopsy. A multimodality, pathway-based approach ensures timely diagnosis, appropriate subtype differentiation, and optimal management across the spectrum of suspected and established cardiac amyloidosis.