Advanced Imaging Modalities in Cardiotoxicity: The Roles of Cardiac CT, MRI, and PET in Cardio-oncology

Purpose of Review: This review explores the updates in the application of advanced cardiac imaging modalities, including cardiac computed tomography (CCT), cardiac magnetic resonance (CMR) imaging, and positron emission tomography (PET) in cardio-oncology. These imaging modalities have distinctive roles in baseline risk stratification, surveillance, and diagnosis of cardiotoxicity. Recent Findings: In recent years, there has been increased recognition of advanced imaging techniques in the field of cardio-oncology. With the advent of newer cancer therapeutics like immunotherapy, there has been a rise in cardiotoxicity related to these agents, including myocarditis, pericarditis, and accelerated atherosclerosis. CMR, in particular, is an essential noninvasive diagnostic test for these immunotherapy-related cardiotoxicities, albeit with diagnostic limitations depending on the disease presentation (Zhang et al. Eur Heart J. 41(18):1733-1743, 2020; Schwartz et al. Am J Med. 82(6):1109-18, 1987). Furthermore, CCT is often used in cardio-oncology patients to rule out CAD, with an expansion of its role in evaluating immune checkpoint inhibitor (ICI) myocarditis and for evaluating accelerated atherosclerosis in patients on ICI therapy (Suero-Abreu et al. JACC CardioOncol. 4(5):598-615, 2022). Coronary artery calcium (CAC) scoring on chest CT in cancer patients is a recommended risk stratification tool in addition to dedicated cardiac testing. At the same time, cardiac PET provides additional information in patients with cardiac masses. Functional testing using cardiac PET coronary flow reserve (CFR) is helpful in patients' baseline risk stratification and diagnosing microvascular disease. Summary: Cardio-oncology is a growing field with increased recognition of newer cardiotoxicities and the advent of more unique cancer treatments. Imaging techniques like echocardiogram and echocardiogram-derived global longitudinal strain (GLS) are the current workhorse for baseline risk stratification, surveillance, and cancer therapy-related cardiovascular toxicity (CTR-CVT) diagnosis. However, additional advanced cardiac imaging modalities play a unique role in risk stratification or surveillance in patients with suboptimal echocardiograms for various factors. Additionally, advanced cardiac imaging techniques are crucial in patients with abnormal echocardiograms or clinical presentations concerning for cardiotoxicity to confirm those findings or establish an accurate diagnosis—for example, CMR in ICI myocarditis or PET for cardiac masses.