Radionuclide imaging in cardio-oncology: A clinical decision-making tool

Nuclear cardiology has become an integral component of cardiovascular care in oncology, providing robust tools for the detection, monitoring, and mechanistic assessment of cancer therapy-related cardiac dysfunction. This review outlines the evolving applications of nuclear imaging across the cardio-oncology continuum, from reproducible quantification of left ventricular ejection fraction with multigated acquisition to advanced molecular imaging with positron emission tomography for the identification of pathobiology. We discuss the utility of radionuclide techniques for early detection of subclinical cardiotoxicity, including phase analysis, metabolic imaging with ¹⁸F-fluorodeoxyglucose, and emerging tracers targeting inflammation, fibrosis, and immune cell activity. Special considerations are given to their role in differentiating ischemic from non-ischemic injury, evaluating cardiac tumors, and guiding therapeutic decisions. Comparative strengths and limitations relative to other imaging modalities are briefly addressed, along with practical considerations such as access, and modality selection. Looking forward, developments in hybrid imaging, artificial intelligence, and targeted radiotracers are poised to enhance risk stratification and enable personalized, mechanism-based cardioprotection. Nuclear cardiology, when integrated thoughtfully into multimodal strategies, will be essential to advancing precision care in cardio-oncology.