Background: Cancer therapy-related cardiac dysfunction (CTRCD) remains a critical limitation of cancer therapy, with implications for morbidity and survivorship. Echocardiography is an established surveillance tool, while electrocardiography (ECG) may offer earlier, low-cost detection of subclinical cardiotoxicity. The relative diagnostic yield of these modalities is uncertain.
Aim: To systematically review and compare echocardiography and ECG for early detection of CTRCD in patients receiving cancer therapy.
Methods: Following PRISMA 2020 guidelines, PubMed, Embase, Scopus, and CENTRAL were searched through May 2025. Eligible studies included prospective or retrospective cohorts reporting echocardiographic and ECG outcomes in adults undergoing chemotherapy. Data on left ventricular ejection fraction (LVEF), diastolic function, global longitudinal strain (GLS), and ECG abnormalities were extracted. Pooled incidence and effect estimates were calculated using random-effects models. Risk of bias was assessed with QUADAS-2.
Results: Thirteen cohort studies involving 1440 patients were included. The pooled incidence of echo-defined CTRCD was 10% (95% confidence interval [CI] 7%-16%), with higher rates among anthracycline-treated cohorts. Diastolic dysfunction and GLS reduction occurred in up to 40% of patients, frequently preceding a decline in LVEF. ECG abnormalities were observed in 35% (95% CI 22%-49%), most commonly QTc prolongation, ST-T changes, fragmented QRS, and atrial fibrillation. Routine ECG demonstrated low sensitivity compared with echocardiography, though continuous monitoring and AI-enhanced ECG showed potential for earlier detection.
Conclusions: Echocardiography remains the cornerstone for CTRCD surveillance, with GLS and diastolic indices providing early warning. ECG abnormalities are frequent but inconsistent predictors; their role may expand with continuous and AI-based approaches. A multimodal surveillance strategy integrating echo and advanced ECG may improve cardio-oncology care.
Keywords: cardiotoxicity; chemotherapy; echocardiography; electrocardiography; meta‐analysis; systematic review.
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