A review of cardiac imaging in anthracycline and HER2 inhibitor induced cardiotoxicity

Abstract Background As cancer survival improves, cancer therapy-related cardiac dysfunction (CRTCD) has emerged as a growing concern, particularly with anthracyclines and HER2 inhibitors. Current imaging strategies rely heavily on left ventricular ejection fraction (LVEF), a late-stage marker of cardiotoxicity with limited reproducibility. Purpose This review evaluates the effectiveness of advanced imaging techniques—especially cardiovascular magnetic resonance (CMR) and global longitudinal strain (GLS)—in detecting subclinical cardiac dysfunction in patients treated with these chemotherapies. Methods A targeted PubMed search identified six high-quality studies (2019–2024) assessing CRTCD using modalities such as CMR, GLS, and myocardial work index. Studies were selected for methodological rigor and relevance to cardiac remodelling in anthracycline and HER2-targeted therapies. Results CMR provided superior tissue characterisation (e.g., T1/T2 mapping, late gadolinium enhancement) and showed promise in detecting early myocardial changes. GLS emerged as a more sensitive tool than LVEF for early systolic dysfunction, particularly in HER2-related Type 2 cardiotoxicity. However, inconsistencies in imaging use, limited access to CMR, and interobserver variability in echocardiography remain significant barriers. Conclusion This review highlights the need to shift from late functional markers like LVEF to earlier structural and strain-based imaging. Advanced modalities such as CMR and GLS should be standardised and integrated into routine monitoring to enable earlier intervention and improve long-term cardiac outcomes in cancer survivors.