ESC guidelines 2025 on cardiovascular disease and pregnancy: considerations and future perspectives

Pregnancy in women with cardiovascular disease (CVD) represents a distinct clinical condition, as the physiological adaptations of pregnancy may interact with underlying cardiac pathology in variable and sometimes unpredictable ways. Consequently, maternal and foetal risk cannot be assumed a priori and requires structured, patient- and disease-specific assessment. The new ESC guidelines on cardiovascular disease and pregnancy incorporate updated evidence following the 2018 version. The contents span from models of multidisciplinary care (the Pregnancy Heart Team, PHT), pre-pregnancy counselling, and pregnancy-related risk assessment, to novel recommendations that are both shared by all pregnancies in women with CVD and specific to each distinct disease. Due to limited prospective or randomized studies largely prevented by ethical reasons, most recommendations are based on evidence level C. This document provides a concise synthesis of innovations in shared management strategies and disease-specific pathways in pregnancy of women with known CVD. It also acknowledges that not all clinical scenarios can be fully captured by guideline-based recommendations. Beyond guidelines, and primarily because approximately 50% of recommendations are Level C evidence, there is considerable decision-making margin for cardiovascular specialists to adhere recommendations. For rare unpredictable complications/events the limited available evidence does not allow recommendations to be made. Looking to the future, the expectation is that AI, which is already generating data and models of care in pregnancy, can help support widespread access to PHT, both in hospitals equipped with the necessary requirements and remotely to all healthcare facilities serving pregnant women with CVDs.