Radiation-associated cardiac disease (RACD) results in complex clinical presentations, unique management issues, and increased morbidity and mortality. Patients typically present years or even decades after radiation exposure, with delayed-onset cardiac damage sustained from high cumulative doses. Multimodality imaging is crucial to determine the manifestations and severity of disease because symptoms are often nonspecific. Comprehensive screening using a coordinated approach may enable early detection. However, timing of intervention should be carefully considered in these patients because surgery is often complex and high-risk second surgeries should be minimized in the long-term. This review aims to provide treating physicians with a comprehensive and clinically focused overview of RACD, including clinical/imaging manifestations, multi-modality screening recommendations, and management options.