Risk stratification in early non-ischaemic cardiomyopathy: the interplay of genetics and cardiac imaging

Preventing sudden cardiac death (SCD) in early non-ischaemic cardiomyopathy (NICM) remains a major clinical challenge. Traditional risk stratification centred on left ventricular ejection fraction (LVEF) poorly captures arrhythmic risk, particularly in early dilated cardiomyopathy (DCM) and non-dilated left ventricular cardiomyopathy (NDLVC). Increasing recognition of fibrosis-based and genotype-specific arrhythmogenic substrates has prompted a shift towards multimodal risk assessment strategies integrating imaging, electrocardiographic, and genetic data. This review examines contemporary approaches to risk stratification in early NICM, with particular emphasis on the role of cardiovascular magnetic resonance (CMR) imaging and late gadolinium enhancement (LGE). The expanding role of genotype-specific phenotyping is also explored, including high-risk arrhythmogenic variants and the integration of genotype with imaging phenotype as a promising route to improved prediction. Collectively, these advances support a transition from population-based LVEF thresholds towards more personalised and biologically informed strategies for prevention of SCD in early NICM.