Toward Precision Cardio-Oncology: Integrating Biomarkers and Cardiac Imaging for Cardiovascular Risk Assessment in Patients With Cancer

Cardiovascular disease and cancer frequently coexist, and cardiovascular toxicity can limit the delivery of effective anticancer therapy and influence long-term outcomes. Conventional cardiovascular risk scores were not designed for oncology populations and do not fully capture treatment-related risk. This narrative review examines how clinical assessment, circulating biomarkers, and multimodality imaging can be combined to refine cardiovascular risk stratification before, during, and after cancer treatment. High-sensitivity cardiac troponins and natriuretic peptides provide complementary information on myocardial injury and hemodynamic stress, whereas echocardiography with global longitudinal strain enables detection of subclinical dysfunction before a fall in left ventricular ejection fraction. Cardiac magnetic resonance, cardiac computed tomography, and selected nuclear imaging techniques provide additional tissue, coronary, vascular, and inflammatory characterization when clinically indicated. Recent validation studies support treatment-specific risk assessment, but important limitations remain, including variable biomarker thresholds, incomplete external validation of risk models, inter-vendor variability in strain measurements, and limited randomized evidence that surveillance strategies improve hard clinical outcomes. A practical precision cardio-oncology approach should therefore integrate baseline risk, treatment exposure, serial biomarker trends, and appropriately selected imaging rather than rely on a single test.