IL-6 in the spotlight: From cardiovascular pathophysiology to therapy

Interleukin-6 (IL-6), a pro-inflammatory cytokine and anti-inflammatory myokine, is involved in immune regulation and metabolic control. Persistent IL-6 activation, particularly via trans-signalling, is implicated in endothelial dysfunction, atherosclerosis, myocardial fibrosis, and adverse remodelling.

This review summarizes experimental, genetic, and clinical evidence on the role of IL-6 in cardiovascular disease (CVD), focusing on the molecular pathways, prognostic value, and its potential as a therapeutic target. Experimental and genome-wide association studies, as well as clinical trials-including IL-6-targeted interventions-are comprehensively reviewed.

While acute activation of IL-6/STAT signalling, that is, before or during myocardial infarction, is protective, chronic activation leads to maladaptive changes in the myocardium. Mechanistically, IL-6 promotes vascular inflammation, monocyte recruitment, coagulation, and fibrosis. Mendelian randomization implies a causal role of IL-6 signalling in coronary artery disease, stroke, and atrial fibrillation. Simultaneously, elevated IL-6 levels predict adverse outcomes in acute coronary syndromes and heart failure. Pharmacological IL-6 inhibition reduces systemic inflammation, with pilot data implying acceptable safety profiles. Large phase III outcome trials are ongoing, shedding light on the impact of IL-6 blockade in high-risk populations, such as those with chronic kidney disease and heart failure with preserved or mildly reduced ejection fraction.

IL-6 plays a dual role-protective versus pathogenic and acute versus chronic. Chronic IL-6 links inflammation and metabolic dysregulation to structural cardiovascular damage. Chronic IL-6 activation requires therapeutic approaches tailored to disease context, timing and signalling mode. The results of ongoing trials will clarify whether IL-6-targeted interventions can be integrated into cardiovascular prevention and management strategies, complementing established therapies and addressing residual inflammatory risk.