Immune checkpoint inhibitors (ICIs) have dramatically changed the landscape of cancer treatment and are increasingly used either as monotherapy or in combination with other ICIs, chemotherapy, and molecularly targeted agents. ICI myocarditis is a rare but potentially fatal irAE associated with the use of ICI characterized by T-cell mediated cardiomyocyte death. Diagnosing ICI myocarditis can be intricate as its atypical presentations. Multimodal imaging plays a crucial role in the diagnosis and risk stratification of ICI myocarditis. Current management strategies for ICI myocarditis include corticosteroids and immunosuppressants. Multidisciplinary collaboration is vital in these cases—combining oncology expertise with cardiology insights.

Early detection and the rise of targeted cancer treatment have led to increased overall survival and decreased mortality among cancer patients. As the cancer survivor population ages, there is an increased risk for cardiovascular disease due to pre-existing comorbidities, deconditioning during therapy, or the natural progression of aging. Furthermore, with emerging oncologic therapies, there is an increased recognition of their potential cardiovascular toxicities. Indeed, heart disease is the leading cause of death in cancer survivors, which may reflect upon both the success of novel oncologic therapies and their potential cardiovascular toxicities. This recognition has driven the development of cardio-oncology, a multi-disciplinary field that involves collaboration between hematologists, oncologists, and cardiologists to screen, prevent, and manage cardiovascular disease in cancer patients and cancer survivors. The field focuses on early cardiovascular detection and prevention for these patients before, during, and after their oncologic treatment. As oncologic therapies evolve and our knowledge of short- and long-term adverse cardiovascular effects grows, it is critical for physicians to identify those at risk for increased morbidity and mortality, while also balancing the importance of their oncologic treatment plan. Multimodality cardiac imaging is the crux of the diagnosis and surveillance of these patients within cardio-oncology, and includes echocardiography, nuclear, computed tomography (CT), and cardiac magnetic resonance (CMR). Cardiac imaging is essential to establish the baseline function and assess various cardiotoxicities, including left ventricular dysfunction, heart failure, atherosclerosis, vascular injury, and arrhythmias. This review will discuss common oncologic therapies and their cardiotoxic profiles, the cardiac multimodality imaging modalities used in cardio-oncology, and the various approaches for the diagnosis and surveillance of this population.

Anthracyclines are cornerstone chemotherapeutic agents for several cancers but carry a substantial risk of cardiotoxicity. Multiple cardioprotective drugs have been investigated to prevent cardiac dysfunction in patients receiving anthracycline-based chemotherapy. This study evaluated and ranked the cardioprotective effects of these agents using network meta-analysis. A comprehensive search of PubMed, Cochrane, Scopus, and Web of Science from inception to September 22, 2024 identified randomized clinical trials and cohort studies assessing cardioprotective agents in cancer patients treated with anthracyclines. Interventions included angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers, beta-blockers, mineralocorticoid receptor antagonists, statins, sodium-glucose cotransporter 2 (SGLT2) inhibitors, and metformin. The primary outcome was change in left ventricular ejection fraction (LVEF). Secondary outcomes were left ventricular end-diastolic diameter (LVEDD), chemotherapy-related cardiac dysfunction (CTRCD), heart failure (HF), HF hospitalization, and all-cause mortality. Thirty-five studies were included, comprising 31 randomized controlled trials and 4 retrospective studies. Overall, cardioprotective therapy significantly improved LVEF, reduced CTRCD, all-cause mortality, HF incidence, and LVEDD, but had no significant effect on HF hospitalization. Subgroup and network meta-analyses showed that ACEIs plus beta-blockers, beta-blockers alone, statins, and ACEIs significantly improved LVEF versus controls, with ACEIs ranking highest. For CTRCD prevention, statins and beta-blockers significantly reduced risk, whereas ACEIs plus beta-blockers had the most favorable ranking. For mortality, the available retrospective SGLT2 inhibitor studies suggested an association with lower risk; however, because no randomized anthracycline-specific SGLT2 inhibitor trials were available and follow-up duration differed from the RCT evidence for other agents, this finding should be considered hypothesis-generating rather than definitive comparative evidence. ACEIs, beta-blockers, and statins appear effective for preserving cardiac function during anthracycline therapy. Treatment rankings, particularly for outcomes supported by sparse or observational evidence, should be interpreted cautiously, and further randomized trials are needed, particularly to evaluate SGLT2 inhibitors.