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Introduction Obstructive sleep apnoea (OSA) is common and linked to adverse cardiovascular outcomes. Cardiac magnetic resonance (CMR) offers a non-invasive, highly sensitive method for detecting early cardiac remodelling, with potential to inform the multidisciplinary care of complex OSA patients.Objective To evaluate the utility of CMR in identifying cardiovascular changes in adults with OSA and its role in guiding and monitoring therapy.Methods A systematic review (PRISMA-compliant) was conducted across six databases. Twenty-one studies were included, reporting on CMR-derived markers of left ventricular hypertrophy, right ventricular function, myocardial fibrosis, and pulmonary hypertension in OSA cohorts.Results CMR consistently detected cardiac remodelling proportional to OSA severity, including elevated LV mass, RV dysfunction, and myocardial fibrosis. Improvements in ventricular metrics were observed following CPAP therapy (3–12 months). However, evidence on surgical intervention outcomes remains lacking. Barriers to widespread CMR use include cost, access, and scan time, though advances in open-scanner and AI-supported imaging may improve feasibility.Conclusion CMR reveals OSA as a subclinical cardiomyopathy, enabling early risk stratification before irreversible damage occurs. Its integration into MDT care and trials of CPAP or surgery could redefine cardiovascular prevention in OSA. Further research should address economic feasibility and the impact of surgical therapies on CMR findings.