Cardiomyopathy — characterisation and assessment

2023 ESC Cardiomyopathies Guideline

Echocardiography measures how the heart moves; cardiac MRI says what the muscle is made of. The pattern and distribution of late gadolinium enhancement is what separates ischaemic from non-ischaemic disease and points to a specific phenotype, and it also carries the arrhythmic risk information that changes device decisions.

New or unexplained ventricular impairment or hypertrophy, a family history of inherited cardiomyopathy or sudden death, suspected infiltrative disease, or an echocardiogram that is discordant with the clinical picture or technically limited.

Referenced decision support — confirm against your local protocol.

Decision support, not a directive. Protocols and timings shown are typical published ones — your local protocol takes precedence, and the vetting radiologist decides.

The request in front of you

Everything is optional. Leave a field alone and the answer assumes nothing — the verdict updates as you go.

Study requested

What the referrer actually asked for. It is evidence of intent, not a constraint on the right answer.

Contrast as written

What the request form says, not what it should say.

Age

Pick a band, or type an exact age if it matters.

years

Pregnancy status

Renal risk factors

The question a vetter can actually answer from the request. An explicit “none known” is a real answer, and it removes checks rather than deferring them.

Previous contrast reaction

The pathway — tap anything already done

Marking a study complete moves the answer on. A patient arrives partway through a pathway far more often than at the start of one.

Accept as requested

Transthoracic echocardiography — standard adult study

Transthoracic echocardiography

What we'd amend, and why

Echocardiography is the first imaging test in every patient with a suspected cardiomyopathy and in every relative being screened, and the ESC pathway assumes it has been done before cardiac MRI is considered. It measures chamber size, wall thickness and its distribution, systolic and diastolic function, valve function and pulmonary pressure in twenty minutes at the bedside, with no radiation, no contrast and no device screening — and in most patients that is the phenotype. It is also what makes the MRI request answerable: the MRI is asked to explain a discrepancy, to characterise an infiltrate, or to find scar that predicts arrhythmia, and each of those questions is defined by what the echo showed. The two places it hands over are exactly the ones this card exists for: a poor acoustic window in obesity, hyperinflation or ventilation, which is a real result rather than a failed study; and any question about tissue characterisation, because echo can measure the muscle but cannot say what it is made of.

Nothing needs resolving before this goes ahead. Routine checks below are owned downstream.

How was this decided?

pathwayadult — Adults

Decision support only. Local protocol takes precedence.

Pathways

Big forks are separate pathways; the first whose conditions match is the one used.

Adults

Matches your inputsDefault

Role	Study & protocol	Why this answers the question
First line	Transthoracic echocardiography Transthoracic echocardiography — standard adult study usually appropriate	Echocardiography is the first imaging test in every patient with a suspected cardiomyopathy and in every relative being screened, and the ESC pathway assumes it has been done before cardiac MRI is considered. It measures chamber size, wall thickness and its distribution, systolic and diastolic function, valve function and pulmonary pressure in twenty minutes at the bedside, with no radiation, no contrast and no device screening — and in most patients that is the phenotype. It is also what makes the MRI request answerable: the MRI is asked to explain a discrepancy, to characterise an infiltrate, or to find scar that predicts arrhythmia, and each of those questions is defined by what the echo showed. The two places it hands over are exactly the ones this card exists for: a poor acoustic window in obesity, hyperinflation or ventilation, which is a real result rather than a failed study; and any question about tissue characterisation, because echo can measure the muscle but cannot say what it is made of.
First line	Cardiac MRI Cardiac MRI — function and late gadolinium enhancement usually appropriate	Gadolinium is an extracellular agent that cannot enter intact myocytes, so it distributes into whatever interstitial space has expanded — scar, infiltrate or oedema — and washes out of it slowly. Imaging ten to fifteen minutes after injection, with the inversion time set to null normal myocardium, turns that difference into a black-and-white map of abnormal muscle. The distribution is what makes the diagnosis: subendocardial or transmural enhancement following a coronary territory means infarction, mid-wall enhancement suggests dilated or inflammatory disease, patchy enhancement at the right ventricular insertion points accompanies hypertrophic disease, and a global subendocardial pattern with abnormal gadolinium kinetics suggests amyloid. The cine stack in the same sitting gives ventricular volumes and mass from direct planimetry, with no geometric assumption — which is why it is the reference when echocardiography is limited or when a device decision hangs on the ejection fraction.
Second line	CT Coronary Angiogram (CCTA) CT Coronary Angiogram — ECG-Synchronised	New ventricular impairment needs coronary disease excluded before it can be called a cardiomyopathy, and in a patient with a low likelihood of obstructive disease CT angiography does that without an arterial puncture. It is complementary rather than competing: the MRI says whether the scar looks ischaemic, and the CT says whether there is a vessel that explains it.

Pitfalls

Requesting the study without contrast. It reduces an aetiological question to a volumetric one and usually leads to a repeat.
Scanning during uncontrolled atrial fibrillation or a fast ventricular rate, which degrades the cine and enhancement sequences the diagnosis rests on.
Reading mid-wall enhancement as diagnostic of a single disease. The pattern narrows the differential; it does not close it.
Missing left ventricular thrombus because early post-contrast imaging was not performed in a dilated, poorly contracting ventricle.
Comparing ejection fractions across modalities. MRI and echocardiography systematically differ, and a device decision should be made on one method used consistently.
Booking cardiac MRI before an echocardiogram has been done, or without knowing what it showed. The MRI is a problem-solving study for a problem the echo defines, and a scanner slot spent restating an unremarkable echo is a slot lost to a patient with a device question.

Priors — what to pull first

Retrieve the echocardiogram report and, where possible, the images. The MRI is being asked to resolve a specific discrepancy, and knowing which one focuses the protocol.
In a familial presentation, previous imaging of affected relatives is often more informative about the expected phenotype than any single measurement in this patient.

What makes a good request

A good request states the echocardiographic findings and their quality, the rhythm and heart rate, the renal function, any implanted device and its MR labelling, and the specific phenotypic question being asked.
Echocardiography comes first in every ESC pathway and is the other correct answer on this card. Where no echo has been done, or where the request does not say what it showed, that is the study to arrange — the MRI is being asked to resolve a specific discrepancy or to characterise a specific phenotype, and without the echo nobody knows which.
Contrast-enhanced cardiac MRI is recommended at the initial evaluation of patients with cardiomyopathy. Requesting it without gadolinium answers the volumetric question and discards the diagnostic one.
Rhythm and breath-hold capacity determine whether the study will be diagnostic. Atrial fibrillation with a fast ventricular response degrades the cine and enhancement sequences, and is worth addressing before the appointment.

Scoring this once it is done

The classification and risk tools this question ends in.

eGFR (CKD-EPI 2021 Creatinine)

How these studies are acquired

Contrast, phases and timing for every study on the pathways above.

Transthoracic echocardiography — standard adult study Cardiac MRI — function and late gadolinium enhancement CT Coronary Angiogram — ECG-Synchronised

Confirm locally

Transthoracic echocardiography — standard adult study: timings are typical — confirm against local protocol.
Timings, contrast volumes and rates above are typical published values. Your department's protocol, scanner and patient population decide the actual numbers.
Safety thresholds and premedication policy follow local policy where it differs from the cited guidance.

References

Implemented from the cited published sources. Educational and workflow support only; confirm against current guidelines and local policy before clinical use.