Abstract
Background. Anthracycline‑induced cardiotoxicity remains a major clinical challenge, as myocardial injury often occurs before overt systolic dysfunction becomes apparent. Although left ventricular ejection fraction (LVEF) is the traditional monitoring parameter, it is a relatively late and insensitive marker. Emerging echocardiographic techniques, particularly myocardial strain imaging and three‑dimensional echocardiography, enable earlier detection of subclinical cardiac dysfunction.
Methods. This narrative review synthesizes current evidence on advanced echocardiographic techniques for the early detection and monitoring of anthracycline‑induced cardiotoxicity. A targeted literature search was conducted in PubMed, Scopus, Web of Science, and Google Scholar to identify relevant English- and Persian-language studies published up to September 2025.
Results. Global longitudinal strain (GLS), along with circumferential and radial strain, and right ventricular free-wall strain, and left atrial strain, significantly improves the detection of subclinical injury and the prediction of systolic dysfunction compared to LVEF. However, clinical implementation faces challenges, including inter-vendor variability in software, undefined clinical decision thresholds, and the economic costs associated with frequent imaging.
Conclusion. Integrating multiparametric echocardiographic assessment, risk-adapted surveillance, and artificial intelligence for automated trend detection will likely shape future cardio-oncology practice and enhance the early management of cardiotoxicity.
Practical Implications. Effective management requires a shift from reactive LVEF monitoring to proactive, strain-based surveillance. Incorporating GLS into baseline and follow-up imaging provides early warning signs of myocardial injury while ventricular function appears preserved, enabling timely cardioprotective interventions. Surveillance frequency should be risk-stratified, and consistency in imaging equipment is essential for reliable longitudinal comparisons.