Precision Cardio-Oncology and Nuclear Imaging: Current Applications, Molecular Innovations, and Future Trajectories

Cardiovascular toxicity has emerged as a major determinant of long-term outcomes in cancer survivors as advances in oncologic therapies continue to improve survival. Conventional cardiac surveillance strategies predominantly rely on functional and structural changes, often identifying myocardial injury after clinically significant damage has occurred. The aim of this narrative review is to critically evaluate the role of nuclear imaging in advancing precision cardio-oncology by enabling earlier, mechanism-based detection and characterization of cancer therapy-related cardiotoxicity. We summarize current clinical applications of PET- and SPECT-based imaging, examine molecular and tracer-level innovations, and discuss emerging hybrid imaging and analytic approaches relevant to individualized cardiovascular risk stratification. Current literature indicates that nuclear imaging provides unique insights into myocardial perfusion, metabolism, inflammation, and microvascular dysfunction, facilitating detection of subclinical injury across diverse anticancer therapies, including anthracyclines, targeted agents, and immune checkpoint inhibitors. By integrating molecular imaging with conventional modalities, nuclear techniques support more personalized surveillance and management strategies. This narrative review highlights nuclear imaging as an emerging complementary modality within precision cardio-oncology supporting earlier detection and risk stratification, and outlines future directions required to optimize its clinical integration and impact on cardiovascular outcomes across the cancer care continuum.