Theranostic advances in cardio-oncology: integrating precision diagnostics and targeted therapies for cardiovascular protection in cancer patients

Cardio-oncology has emerged as a critical interdisciplinary field addressing the growing burden of cardiovascular complications arising from modern cancer therapies. While advances in chemotherapy, targeted agents, and immunotherapies have substantially improved cancer survival, they have concurrently led to a significant rise in cancer therapy-related cardiac dysfunction (CTRCD), contributing to increased long-term morbidity and mortality among cancer survivors. Conventional surveillance strategies often detect cardiotoxicity only after irreversible myocardial injury has occurred, accentuating the need for more precise, proactive, and personalized approaches. Theranostics, integrating diagnostic imaging, molecular biomarkers, and targeted therapeutics, offers a promising paradigm to enable early detection, risk stratification, and tailored cardioprotective interventions in cardio-oncology. This review synthesizes recent advances in theranostic strategies relevant to cardio-oncology, spanning imaging-based, biomarker-driven, and nanotechnology-enabled approaches. Advanced imaging modalities such as hybrid PET/MRI, AI-enhanced echocardiography, and novel molecular radiotracers [e.g., 68Ga-FAPI, 18F-DHMT, [68Ga]pentixafor] enable early identification of subclinical myocardial injury, inflammation, fibrosis, and metabolic dysfunction before overt declines in left ventricular ejection fraction occur. Complementing imaging, biomarker-driven theranostics including high-sensitivity cardiac troponins, natriuretic peptides, circulating and exosomal microRNAs, and cardiomyocyte-specific cell-free DNA, provide minimally invasive, real-time insights into myocardial stress, injury, and immune-mediated cardiotoxicity. Nanotheranostic platforms, such as liposomal doxorubicin and immunomodulatory nanoparticles, further enhance therapeutic precision by reducing off-target cardiac exposure while preserving antitumor efficacy. Despite these advances, clinical translation remains hindered by interdisciplinary fragmentation, limited access to advanced infrastructure, high development costs, regulatory heterogeneity between agencies, and reliance on surrogate endpoints rather than long-term cardiovascular outcomes. Theranostics represents a transformative approach in cardio-oncology. Integration of advanced imaging, molecular biomarkers, artificial intelligence, and nanotechnology holds significant promise for preserving cardiac health without compromising oncologic success. Embedding theranostic strategies into routine cardio-oncology practice is essential to advancing precision medicine and improving cardiovascular outcomes for cancer patients worldwide.