Cardiovascular Magnetic Resonance for Early Detection of Cancer Therapy-Related Cardiac Dysfunction: From Multiparametric Tissue Signatures to Clinical Pathways

Cancer therapy-related cardiac dysfunction (CTRCD) can compromise cardiovascular health and the delivery of anticancer treatment. Echocardiography and cardiac biomarkers remain the first-line surveillance tools; cardiovascular magnetic resonance (CMR) provides complementary assessment of ventricular function and myocardial tissue when findings are inconclusive or additional characterization may change management. This narrative review examines multiparametric CMR across seven anticancer treatment groups and proposes a risk-adapted approach to its clinical use. Cine imaging, T1 and T2 mapping, extracellular volume fraction (ECV), late gadolinium enhancement, and feature-tracking strain provide different, partly overlapping information. Serial interpretation requires attention to local reference ranges, measurement reproducibility, hematocrit, and acquisition and analysis consistency. An absolute ECV increase of at least 3 percentage points is discussed as an observational risk signal, not proof of collagen deposition or a validated treatment threshold. The guideline threshold of a greater than 15% relative decline in global longitudinal strain derives from echocardiography and should not be assumed to apply directly to CMR feature tracking. We distinguish guideline-supported practice, randomized evidence, observational evidence, and mechanistic extrapolation from the authors’ proposed surveillance and rechallenge framework. Suspected immune checkpoint inhibitor myocarditis requires urgent clinical evaluation even when CMR is negative. Prospective trials are needed to establish whether CMR-informed management improves cardiovascular outcomes, treatment completion, or survival.