Multimodality Imaging in Contemporary Cardio-Oncology: Beyond Ejection Fraction

Background: Cancer therapy-related cardiac dysfunction (CTRCD) may develop before symptoms or a measurable decline in left ventricular ejection fraction (LVEF). Surveillance therefore requires assessment beyond LVEF alone. Content: This narrative review examines cardiotoxic mechanisms, imaging findings, and treatment-specific surveillance. Transthoracic echocardiography with LVEF and global longitudinal strain remains the first-line approach. Myocardial work may provide additional information, but oncology-specific action thresholds remain unvalidated. Cardiac magnetic resonance complements echocardiography when measurements are inconclusive or tissue characterization is required. Mapping abnormalities are nonspecific and do not independently establish treatment-related injury. Nuclear imaging addresses selected diagnostic questions; fibroblast activation protein inhibitor PET remains investigational. Artificial intelligence may support image analysis and data integration, although evidence from general cardiovascular populations requires oncology-specific validation. An algorithm and surveillance matrix link clinical findings, treatment, baseline risk, imaging, and biomarkers. Conclusions: A tiered approach organizes surveillance around specific clinical questions. Earlier detection should be distinguished from demonstrated clinical benefit: evidence that imaging-guided strategies improve long-term cardiovascular outcomes remains limited. Prospective studies are needed to validate emerging markers, AI applications, and the clinical and economic effects of integrated surveillance pathways.