Direct Cardiac Reprogramming in the Omics Era: Advances, Mechanisms, and Applications

Cardiovascular disease remains the leading cause of death worldwide, with its disease burden continuing to rise. After cardiac injury, most commonly ischemia from myocardial infarction, irreversible loss of cardiomyocytes (CMs) occurs, and the damaged myocardium is replaced by fibroblast (Fib)-derived scar tissue. Because adult CMs have limited regenerative capacity, repair is limited, cardiac function progressively declines, and patients often develop heart failure. Direct cardiac reprogramming-converting Fibs into induced CM-like cells (iCMs)-has emerged as a promising strategy to restore contractile myocardium. Omics-based approaches have greatly advanced understanding of the mechanisms that enable or hinder iCM generation. Single-cell transcriptomics have delineated gene expression trajectories and intermediate cell states, while epigenomic studies have revealed how chromatin accessibility, histone modifications, and DNA methylation shape cell fate conversion. Post-transcriptional analyses further highlight the importance of RNA processing and translational control, and proteomic profiling has demonstrated rapid remodeling of protein networks and paracrine signaling during reprogramming. In parallel, metabolic studies have linked shifts in metabolite flux to iCM maturation. Together, these multi-omics investigations provide an integrated framework for defining both barriers and facilitators of Fib-to-iCM conversion. This review synthesizes recent omics-based insights into direct cardiac reprogramming and discusses future directions for advancing its clinical application.