Multiparametric Cardiac MRI In Myocarditis, Non-ischaemic Cardiomyopathies and Silent Myocardial Ischaemia: Diagnostic and Prognostic Integration in Modern Cardiology

Abstract

Cardiac magnetic resonance imaging, more precisely cardiovascular magnetic resonance (CMR), has moved from a predominantly morphological tool to a comprehensive method for myocardial tissue characterisation, perfusion assessment, and risk stratification. Its strongest contemporary contribution lies in multiparametric integration, whereby cine imaging, late gadolinium enhancement, T1 mapping, T2 mapping, extracellular volume estimation, and stress perfusion are interpreted together rather than in isolation. This integrated approach is particularly valuable in myocarditis, non-ischaemic cardiomyopathies, and silent myocardial ischaemia, three settings in which symptoms and routine tests often underestimate the true extent or nature of myocardial disease. In myocarditis, CMR has improved non-invasive diagnosis through the updated Lake Louise framework and has also emerged as a prognostic tool through the identification of residual scar, ventricular dysfunction, and persistent tissue abnormality. In non-ischaemic cardiomyopathies, CMR refines phenotyping across dilated, hypertrophic, infiltrative, and inflammatory disorders while adding prognostic information that extends beyond left ventricular ejection fraction alone. In silent myocardial ischaemia, stress perfusion CMR and scar imaging can reveal inducible perfusion abnormalities, microvascular dysfunction, and unrecognised infarction, thereby linking clinically occult disease to future cardiovascular events. The central modern challenge is no longer whether CMR can detect abnormality, but how its multiple qualitative and quantitative signals should be synthesised with clinical data, biomarkers, and sometimes genetics to guide management. This review examines the diagnostic and prognostic value of multiparametric CMR across these three domains and argues that its greatest importance in contemporary cardiology lies in biologically informed integration rather than single-sequence interpretation.