Cardiac imaging biomarkers of heart failure in diabetes for phenotyping, risk stratification, and evaluating therapeutic response

Type 2 diabetes mellitus (T2DM) is a well-established risk factor for the development of heart failure (HF), yet HF risk within this population is highly heterogeneous. Appropriate biomarker selection and a limited mechanistic understanding of the phenotypic subtypes of HF in T2DM remain barriers to both risk stratification and therapeutic development. Cardiac imaging-based biomarkers are emerging as versatile tools for assessing myocardial dysfunction in T2DM and may enable a shift toward non-invasive, comprehensive, and precise disease assessment. Advances in cardiac MRI, echocardiography, CT, PET, and metabolic imaging have enhanced detection of myocardial fibrosis, diastolic dysfunction, and early functional impairment, as well as assessment of response to contemporary metabolic therapies. This review synthesizes recent imaging evidence to deepen our understanding of HF mechanisms in T2DM and to improve early risk stratification and surveillance strategies. Artificial intelligence-based imaging applications in T2DM with HF and other cardiomyopathies, including radiomics analyses and prediction tasks, will also be discussed with respect to their potential to further refine HF phenotyping and risk assessment.