A Clinician’s Guide to Cancer Therapy-Related Cardiovascular Toxicity

Advances in cancer therapy have substantially improved survival, resulting in a rapidly growing population of cancer survivors. Consequently, cardiovascular disease has emerged as a major determinant of long-term morbidity and mortality, establishing cancer therapy-related cardiovascular toxicity as a central challenge in contemporary cardio-oncology. Modern oncologic therapies produce a broad spectrum of cardiovascular complications, including heart failure, arrhythmias, myocarditis, vascular toxicity, thromboembolic disease, valvular abnormalities, pulmonary hypertension, and autonomic dysfunction. These toxicities arise through diverse mechanisms, including direct myocardial injury, endothelial dysfunction, immune-mediated inflammation, cytokine excess, metabolic derangements, and neurohormonal alterations. This review provides a clinician-oriented, mechanism-based overview of cancer therapy-related cardiovascular toxicity in the modern era. Major therapeutic classes are discussed, including anthracyclines, human epidermal growth factor receptor 2 (HER2)-targeted therapies, tyrosine kinase inhibitors, immune checkpoint inhibitors (ICIs), chimeric antigen receptor T cell therapies, radiation therapy, endocrine therapies, and emerging targeted agents. The review also highlights evolving cardiovascular toxicity phenotypes, radiation-induced heart disease, and the growing relevance of cardiac amyloidosis within the cardio-oncology spectrum. Moreover, contemporary strategies for cardiovascular risk assessment, imaging and biomarker surveillance, cardioprotection, and therapy-specific management are reviewed, with an emphasis on practical clinical application. Finally, current knowledge gaps, survivorship considerations, and future directions are discussed, including artificial intelligence-assisted risk stratification. Overall, by integrating mechanistic understanding with practical management frameworks, this review aims to provide clinicians with a comprehensive resource for the prevention, detection, and treatment of cardiovascular complications associated with modern cancer therapies.