A new review argues that current imaging approaches must evolve to reflect the physiological complexity and multimorbidity common in later life. Writing in JACC: Advances, researchers examined the growing challenges and emerging innovations in noninvasive cardiac imaging for older adults. They highlighted the structural and functional changes in the heart, which can both mimic and mask disease. “These changes can also mimic or obscure pathology, complicating the interpretation of standard imaging if age-specific norms are not considered,” wrote the paper’s authors, led by Krishna K. Patel, MD, from the Icahn School of Medicine at Mount Sinai in New York. “Advances in imaging technology, including artificial intelligence and hybrid protocols, offer opportunities to improve accuracy, access, and individualized decision-making.” Strengths and limitations The review discussed the strengths and limitations of each imaging modality, from echocardiography to cardiac CT, nuclear imaging and cardiac MRI, while highlighting real-world barriers such as frailty, arrhythmias, renal dysfunction and limited mobility. Heavy coronary calcification, a condition common in older adults, can reduce CT accuracy due to “blooming” artifacts, while long MRI protocols may be difficult for patients who cannot lie flat or hold their breath. The review also looked at AI-enabled tools, such as echocardiography, CT and MRI that are emerging as major contributors to more efficient and precise assessments. Despite its promise, the authors warned that algorithmic bias remained a significant threat if data from older adults did not play a larger role in training datasets. “Older adults remain underrepresented in imaging trials,” wrote the paper’s authors. “Large studies are needed to inform test selection, define age- and sex-specific thresholds, and assess outcomes.” Clinical guidelines update The research team also called for major updates to clinical guidelines noting that few guidelines currently consider geriatric-focused recommendations. This is despite the growing reliance on imaging to guide valve interventions, heart failure management and ischemia evaluation. “Guideline development must integrate patient-centered considerations such as frailty, comorbidities, and life expectancy through multidisciplinary collaboration among geriatricians, radiologists, and cardiologists,” wrote the investigators. In conclusion, the team advocated for a patient-centered, multimodality approach that acknowledged the realities of aging. They noted that improving equity in access, through portable imaging technologies, protocol optimization and AI support, would be essential as the population continued to age. Source: Patel KK, Strom J, Syed MA, et al. Noninvasive Cardiac Imaging in Older Adults: Diagnostic Challenges and Prognostic Implications Across Modalities. JACC Adv. 2025 November 17. (Article in Press). Image Credit: New Africa – stock.adobe.com