Circulating Biomarkers in Cardio-Oncology: Prediction and Prognostication

Circulating biomarkers are increasingly utilized in cardio-oncology for risk stratification, early detection, and prognostication of cancer therapy-related cardiovascular toxicity. This review summarizes the current evidence supporting established and emerging biomarkers, with a focus on their clinical utility and limitations.

Cardiac troponins and natriuretic peptides remain the most widely studied biomarkers, with troponins demonstrating consistently strong prognostic value and natriuretic peptides showing more variable predictive performance for cardiotoxicity. Emerging data highlight limitations in biomarker-guided therapeutic strategies, with inconsistent evidence for improved clinical outcomes. Novel biomarkers, including soluble suppression of tumorigenicity 2 (sST2), galectin-3, myeloperoxidase (MPO), inflammatory markers, and circulating microRNAs, show early promise for detecting subclinical injury through distinct pathophysiological pathways but lack standardization and validation for routine clinical use. Imaging biomarkers, including global longitudinal strain (GLS) and cardiac MRI parametric mapping, complement circulating markers and are increasingly integrated into surveillance strategies, with emerging randomized evidence supporting GLS-guided cardio-protection. Increasing emphasis has been placed on multimarker approaches and their integration with imaging and clinical context to improve diagnostic accuracy, although prospective validation of these strategies remains needed. Circulating biomarkers play an increasingly important role in contemporary cardio-oncology practice; however, no single biomarker is sufficient to guide management across all clinical scenarios. A multimodal strategy incorporating biomarkers, imaging, and clinical assessment is increasingly recommended. Future research should focus on standardization, validation of emerging biomarkers, and defining the role of biomarker-guided interventions to improve cardiovascular and cancer outcomes.