The 2025 ESC guidelines for the management of cardiovascular disease and pregnancy1 address the need for an updated review of the previous recommendations. A special effort has been made to provide clear information, supported by summary tables, graphical abstracts, and flow charts that enhance clinical applicability.

Cardiovascular disease (CVD) is now the leading cause of nonobstetric mortality in pregnant women,2 with a rising incidence of acquired heart disease. There is striking evidence linking adverse pregnancy outcomes (APO) to a patient's future cardiovascular risk. Growing data have emerged regarding the risks for both the mother and the foetus during pregnancy and postpartum, as well as the use of medications during preconception, pregnancy, and lactation. Consequently, the new guidelines include an updated risk stratification system (mWHO 2.0) for different cardiac conditions and integrate information on genetic counselling and risk assessment tools.3

Research supports the benefits of a multidisciplinary approach in these patients. As a result, there is a growing emphasis on the establishment of Pregnancy Heart Teams (PHT) as a central component of care.

Finally, contemporary cardiovascular care in pregnancy reflects a shift away from paternalistic models toward patient-centered approaches, in which autonomy is prioritized through joint and informed decision-making.

The updated guidelines reflect a more granular understanding of the various CVD that may affect pregnant women. New sections have been introduced, dedicated to conditions that were previously less detailed or grouped within broader categories, such as inherited cardiomyopathies (eg, hypertrophic myocardiopathy), primary arrhythmic syndromes (channelopathies), pulmonary arterial hypertension (PAH) independently of congenital heart disease (CHD), cardio-oncology, previous cardiac transplantation, arrhythmogenic mitral valve prolapse, and APO.

The PHT was introduced in previous guidelines, but its role is now more strongly emphasized (figure 1). A staged approach is advocated, from preconception through postpartum, with individualized risk stratification.4

Figure 1.

Central illustration. Main role of the pregnancy heart team for pregnant women. The team provides specialized, multidisciplinary care, reduces maternal and foetal complications, and prevents long-term cardiovascular disease to avoid adverse pregnancy outcomes. CMP, cardiomyopathy.

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The mWHO 2.0 includes additional CVD incorporating risk modifiers derived from the CARPREG II score.3 The PHT should guide and oversee care for patients with risk levels II to III and above. The mWHO 2.0 allows reclassification of conditions not included in the previous version, such as coronary artery disease, long QT syndrome, arrhythmogenic right ventricular cardiomyopathy, and transposition of the great arteries repaired with arterial switch. Nonetheless, the guidelines place strong emphasis on patient autonomy and shared decision-making. In this context, a complete risk evaluation should be performed before pregnancy, and women and their partners should be offered structured psychosocial support.

Pharmacotherapy during pregnancy and lactation has also been revised. The updated drug table offers more detail than in previous versions. Greater focus has been placed on anticoagulation, including a scheme of regimens based on clinical indications. Notably, the novel recommendation to consider statin use during pregnancy, which was previously contraindicated, is highlighted for specific clinical scenarios. Detailed information is also provided regarding ionizing diagnostic or therapeutic tools, as well as the nonadvised use of agitated saline and gadolinium-based contrast agents.

A separate chapter provides a comprehensive review of peripartum cardiomyopathy. A key update is the recommendation to conduct genetic testing in these patients, given the high prevalence of pathogenic or likely pathogenic variants in genes associated with dilated cardiomyopathy. Standard heart failure treatment is advised for at least 1 year following full recovery of left ventricular ejection fraction.

The chapter on hereditary aortopathies covers syndromic and non-syndromic forms, including bicuspid aortopathy. An individualized management approach is proposed, integrating factors such as aortic morphology, underlying pathology, family history, and genetics—particularly when determining thresholds for prophylactic aortic surgery before pregnancy or deciding on the delivery method.

A novel tool in the guidelines is a table summarizing risks, monitoring, and management during pregnancy and delivery in women with CHD. More precise classification is now possible for patients with Ebstein's anomaly and Fontan circulation, with clearer criteria for assigning Fontan patients to group IV.

PAH has its own dedicated section with detailed recommendations for management during pregnancy and delivery, highlighting the importance of postpartum care.

Among the key updates on venous thromboembolic disease in pregnancy are more detailed prophylaxis recommendations, increased emphasis on rapid diagnosis, and the requirement for immediate initiation of low-molecular-weight heparin (LMWH) upon clinical suspicion.

The chapter on acquired conditions addresses acute (ACS) and chronic coronary syndromes, hypertensive states, arrhythmias, and valvular diseases. Particular attention should be paid to the evaluation of chest pain during pregnancy, where life-threatening causes must be excluded. New algorithms have been introduced for pulmonary embolism, acute aortic syndrome, and spontaneous coronary artery dissection. In patients with high- or very-high-risk ACS, the recommendation for immediate coronary angiography and percutaneous coronary intervention, when appropriate, has been upgraded. In patients requiring coronary stent implantation, aspirin and clopidogrel are recommended as in non-pregnant women. Additionally, the guidelines propose updates for cardiac arrest and ventricular arrhythmias (VA), including continuous manual left uterine displacement and establishing intravenous access above the diaphragm. Electrical cardioversion is recommended as initial therapy, and beta-blockers are preferred to prevent recurrences. In summary, in life-threatening situations, treatments should mirror those used in non-pregnant patients.

Management of hypertensive disorders of pregnancy includes notable updates, such as the revised definition of preeclampsia (extending beyond proteinuria)5 and new recommendations for the management of mild hypertension. Pharmacologic therapy is now recommended for systolic blood pressure ≥ 140mmHg or diastolic ≥ 90mmHg, marking a shift from prior permissiveness. A target of <140/90mmHg is established for all pregnant women. Detailed recommendations on pharmacological management during pregnancy and postpartum are provided.

The arrhythmia section includes several practical, clinically oriented management algorithms and expands its scope to conditions not previously covered, such as the approach to different types of VA.

The section on valvular heart disease provides a review of the impact of these conditions—particularly stenotic lesions—on maternal and fetal prognosis. A key strength is the inclusion of practical figures and algorithms, including red flags to support risk stratification. When intervention is required during pregnancy, percutaneous procedures are preferred over open valve surgery.

The guidelines highlight the essential role of prepregnancy counselling and optimization. Updated guidance is offered on anticoagulation for mechanical heart valves (MHV). Decisions regarding anticoagulation in each trimester now consider not only prepregnancy vitamin K antagonist dosage but also additional thrombotic risk factors. A detailed approach to reinitiating anticoagulation after delivery is also outlined. Importantly, in women contemplating pregnancy, the recommendation to use a bioloprosthetic prosthesis when valve replacement is needed has been upgraded from class IIa to class I.6 Consultation with the PHT is a class I recommendation before surgery.

Vaginal delivery remains the preferred mode of delivery, with an upgraded class I B recommendation, except for patients on vitamin K antagonist therapy, those with severe heart failure (left ventricular ejection fraction <30% and/or NYHA class III/IV), those with high-risk aortopathy, and those with hypertrophic cardiomyopathy with severe left ventricular outflow tract obstruction.

Finally, a completely new section reflects the growing recognition of the importance of APO in women's future cardiovascular risk.7 APO include pre-eclampsia and gestational hypertensive disorders, gestational diabetes mellitus, preterm birth, and infants who are small or large for gestational age; the relationship is less conclusive for placental abruption or pregnancy loss. Cardiovascular risk assessment is recommended for women with APO, along with appropriate counselling and follow-up—ideally in dedicated women's cardiovascular clinics.

The comprehensive structural reorganisation of care for CVD and pregnancy and its implementation in daily clinical practice requires more than awareness; it demands strategic alignment of care structures at every level. The goal is to move from isolated efforts to integrated, scalable models that are efficient, equitable, and sustainable. Crucially, this transition must ensure access to specialized care while safeguarding reproductive autonomy through transparent counselling, psychological support, and shared decision-making.8 These are not ancillary elements but essential components of high-quality cardiovascular care in pregnancy.

While the roles and composition of core and extended PHT are well delineated in the document, definitions alone do not guarantee improved outcomes. The next step lies in embedding these teams within operational pregnancy heart networks, ideally built around a “hub-and-spoke” model. This approach enhances coordination, optimizes resources, ensures continuity of care, and facilitates timely access to the appropriate level of expertise.9,10 Not every patient requires every resource, but every patient must have access to what they need, when they need it.

Within this model, primary and secondary care providers act as spokes and often represent the first point of clinical contact for women with suspected or confirmed CVD (now encompassing a broader spectrum beyond CHD). They play a central role in early, dynamic risk assessment, a cornerstone of the updated recommendations. This process should ideally begin prior to conception, as timely identification of high-risk patients during reproductive planning opens a window for anticipatory counselling, tailored education, and coordinated multidisciplinary interventions. At this stage, procedures such as valvular repair, arrhythmia ablation, or device implantation can be performed more safely and effectively before pregnancy introduces additional complexity and risk.

To fulfil this role, spokes must have access to updated guideline recommendations and efficient decision-support tools that reduce cognitive load and time constraints in busy clinical settings. Primary care professionals (nurses, midwives, physicians, and gynecologists) should be trained in early detection. Integrating validated scores (such as the mWHO 2.0 classification and CARPREG II risk modifiers), into electronic health records can facilitate rapid risk categorization and generate alerts for early referral or shared assessment.11 In parallel, direct and bilateral communication with hub centres is essential to ensure seamless escalation of care and collaborative decision-making.

Tertiary centers, acting as hubs, provide high-level expertise though established PHTs and standardized clinical pathways covering the full continuum of care, from preconception to postpartum care, with a well-defined, organized transition to long-term care. The clearer guidance offered in previously uncertain areas, such as emergency scenarios (cardiac arrest, ACS, or pulmonary embolism), anticoagulation strategies, arrhythmia management, hypertensive disorders, care of transplant recipients, and the rational use of medications during pregnancy and lactation must be translated into institutional protocols to reduce practice variability and ensure consistent, evidence-based care delivery.

This network-based model aligns all stakeholders involved in cardiovascular care during pregnancy and expands access to expert input, ultimately supporting high-quality outcomes. Its success depends on clearly defined roles and responsibilities, efficient communication, mutual accountability, and sustained institutional commitment.

Implementing the 2025 ESC guidelines as functional pregnancy heart networks will require investment in infrastructure, continued professional education, and technological integration to support risk stratification and care coordination. The aim extends beyond immediate outcomes: prioritizing these efforts will not only improve maternal health but also significantly enhance long-term cardiovascular prognosis, especially for women with adverse pregnancy events such as hypertensive disorders or gestational diabetes, who face a well-established elevated risk of future cardiovascular disease.12

The level of evidence for each recommendation in this guideline follows the standard classification into 3 levels. Because pregnant women are routinely excluded from randomized clinical trials, studies focusing on this population are scarce and often involve small sample sizes. Given these limitations, it is not surprising that only 1 recommendation achieves level A evidence, while the remainder are classified as level B or C.

The task force emphasizes the importance of maternal risk assessment, encompassing imaging procedures, biomarker analysis (eg, natriuretic peptides, cardiac troponin), and functional testing, particularly cardiopulmonary exercise testing. However, the document does not provide cut-off values for identifying high-risk patients.13 Moreover, evidence regarding the physiological evolution of biomarkers during pregnancy and postpartum remains limited.

Regarding diagnostic imaging, transthoracic echocardiography remains the first-line modality. The use of valve area measurements is preferred over flow-dependent methods. However, no established cutoff values exist to distinguish physiological changes from significant valve deterioration during pregnancy.

For ethical reasons, evidence on drug use during pregnancy and lactation cannot rely on randomized trials. Consequently, the evidence base for many medications remains limited. For instance, LMWHs are widely prescribed during pregnancy, but clear evidence on optimal dosing or frequency is lacking. Outcome data on direct oral anticoagulants derive mainly from pharmacovigilance databases; their fetal effects and the safety of specific reversal agents remain topics of ongoing debate. Similarly, PCSK9 inhibitors and ezetimibe are not recommended during pregnancy due to the absence of clinical data. The guidelines do not distinguish between the safety of hydrophilic vs lipophilic statins.

The guideline provides valuable recommendations on prophylactic surgery and mode of delivery for women with aortopathies. However, guidance remains limited for low-prevalence conditions such as Loeys-Dietz syndrome and nonsyndromic heritable thoracic aortic disease, as well as for assessing the risk of type B dissection in patients with prior type A dissection.14 In patients with a bicuspid aortic valve, the increased risk of dissection associated with the “root phenotype” warrants confirmation during pregnancy but is not specifically addressed in the general recommendations.

In CHD, evidence gaps persist regarding the growing Fontan population, including their high risk of infertility and the safety of in vitro fertilization in this group.

Similarly, despite dedicated management strategies for PAH, evidence remains insufficient to guide escalation of pulmonary vasodilator therapy during pregnancy or to determine whether women with mild PAH can pursue pregnancy with acceptable risk. To date, no validated PAH cutoff reliably predicts maternal or fetal outcomes.

The low level of evidence in certain clinical scenarios, such as spontaneous coronary artery dissection, is also noteworthy. In this context, a conservative approach to revascularization is recommended for clinically stable women, yet optimal medical management remains uncertain.15

There remains an evidence gap regarding the use of bromocriptine in peripartum cardiomyopathy.

Despite several registries and studies, management of MHV during pregnancy is challenging for both maternal and fetal care. MHV patients with a well-controlled international normalized ratio are classified as mWHO 2.0 class III, whereas those with an uncontrolled international normalized ratio are not specifically categorized. When LMWH is used during pregnancy in patients with MHV, the optimal anti-Xa range has not been determined.

In atrial fibrillation, the use of antiarrhythmic drugs is supported by limited evidence in pregnancy. A major gap concerns the indication for anticoagulation. The guideline recommends applying the same criteria as in non-pregnant women, using the CHA2DS2-VA score, which assigns 1 point for ages 65 to 74 years and 2 points for age ≥ 75 years. Understandably, this score has not been validated in pregnancy.

The new guidelines also highlight the importance of postpartum care and long-term management. They provide a simple and practical algorithm for the follow-up of women with APO. However, optimal strategies for long-term surveillance still need to be established. These should include not only classical cardiovascular risk factors but also social and environmental determinants.

In summary, as expected, the level of scientific evidence remains limited due to the routine exclusion of pregnant women from clinical studies for ethical reasons. Despite persistent gaps in evidence—particularly in risk stratification, drug safety, management of uncommon conditions, and long-term follow-up—these guidelines represent a critical and timely consensus document for the management of cardiovascular disease in pregnancy, providing clinicians with essential direction in a complex and high-risk field.

None.

No artificial intelligence was used to generate the content of this article.

The conflicts-of-interest declaration documents for all authors are available in the supplementary data.