Top Things to Know: Uses of CV Imaging in Contemporary Cardio-Oncology

Published: September 21, 2023

  1. Cardiotoxicity is recognized as a limitation of some cancer therapies, which have markedly increased in number, types, and targets. Concurrent with the need to better understand the potential cardiotoxicities associated with novel and established cancer therapies have been advances in cardiovascular imaging techniques, offering new approaches to understanding, diagnosing, and managing cardiovascular disease in many populations, including cancer.
  2. Imaging in cardiotoxicity evaluation has traditionally focused on the measurement of the left ventricular ejection fraction (LVEF). Because of an increasing awareness that cardiovascular disease (CVD) in oncology settings extends further, there is a need for consensus on the optimal use and application of cardiac imaging among patients receiving anti-cancer therapies.
  3. The purpose of this scientific statement is to provide an update on the uses of cardiac imaging in patients receiving cancer therapy, specifically the role and use of echocardiography (echo), cardiovascular magnetic resonance (CMR), cardiovascular computed tomography (CCT), cardiac single-photon emission computerized tomography (SPECT), and cardiovascular positron emission tomography (PET), in clinical cardio-oncology scenarios such as myocarditis, heart failure, and arrhythmias.
  4. Cardiotoxicity definitions have evolved since the first identification of heart failure resulting from anthracycline therapy in the 1970s. The most common are heart failure and asymptomatic decreases in LVEF, myocarditis, arrhythmias, vascular toxicities, and hypertension.
  5. Imaging markers have been identified in cardio-oncology that provide an objective way to detect, measure, and reproducibly quantify cardiotoxicity prior to the development of irreversible organ damage, allowing a pathway of care to be created for the patient. These imaging biomarkers include LVEF, strain, fibrosis, and T1/T2 mapping.
  6. Specific clinical applications and uses of cardiac imaging in the care of the patient with cancer are discussed including the methods of echocardiography, CMR, cardiac CT, and cardiac PET/nuclear imaging, in adult and pediatric populations.
  7. Higher rates of cancer-specific and overall mortality have been demonstrated among African American patients, yet the data for racial disparities in CV imaging among cancer patients are sparse. Medicare data have shown a lower use of transthoracic echo among Black women compared to other races. CV imaging in this population can provide objective measures for clinical studies addressing disparities in cardio-oncology care and outcomes.
  8. Integration of CV imaging into oncologic and CV clinical care represents a major shift from the historical practice of LVEF assessment prior to cancer treatment with chemotherapies. Multiple considerations will be needed to continue this process as new cancer therapies and cardiotoxicities are identified.
  9. Evidence gaps indicating future research directions are identified, including the expansion of cardiotoxicity definitions, the rapid expansion of cancer treatments, and increasing the use of CV imaging among patients who need it most, such as those with breast cancer.
  10. As cancer survival continues to improve, there is a critical need to identify and treat patients with adverse CV outcomes related to prior and ongoing cancer therapies. This statement offers practical guidance for the use of imaging in the care of the contemporary cancer patient.


Addison D, Neilan TG, Barac A, Scherrer-Crosbie M, Okwuosa TM, Plana JC, Reding KW, Taqueti VR, Yang EH, Zaha VG; on behalf of the American Heart Association Council on Cardiovascular Radiology and Intervention; Cardio-Oncology Committee of the Council on Clinical Cardiology and Council on Genomic and Precision Medicine; and Council on Cardiovascular and Stroke Nursing. Cardiovascular imaging in contemporary cardio-oncology: a scientific statement from the American HeartAssociation [published online ahead of print September 21, 2023]. Circulation. doi: 10.1161/CIR.0000000000001174