Essential messages and limitations from the 2025 ESC Guidelines for the management of

Cardiovascular Disease and Pregnancy

Written by Dr. Süleyman Atalay

Reference:De Backer J, et al. 2025 ESC Guidelines for the management of cardiovascular disease and pregnancy. Eur Heart J. 2025. doi: 10.1093/eurheartj/ehaf193.

Essential messages

• A Pregnancy Heart Team should be involved in the risk assessment, counselling and management of women in mWHO 2.0 class ≥II–III from pre-conception to the late postpartum. Each woman should have a detailed delivery plan agreed in advance.
• In women with known CVD, a complete clinical re-evaluation should take place prepregnancy to estimate risk, optimize treatment, consider and evaluate the removal of contraindicated drugs, and reduce the probability of complications.
• Women and their partner (if any) should be offered structured psychosocial support  during the entire trajectory, especially for those at high risk and those considering  pregnancy termination.
• Women with known heritable cardiovascular disorders should be counselled about the  transmission risk, including the option for assisted reproductive technology.
• Management of women with CVD who are pregnant or wishing to become pregnant  should be individualized and performed according to a shared decision-making model,  respecting the woman’s autonomy.
• Women in mWHO 2.0 class IV should be comprehensively counselled about the very  high pregnancy risk, being careful to promote a detailed and transparent dialogue about  the heightened maternal and foetal risks associated with pregnancy. A shared decisionmaking process is essential, allowing for informed choices, including the consideration of pregnancy termination if necessary.
• Vaginal delivery is the first choice for the majority of women with CVD. In a lifethreatening situation, treatments such as defibrillation, interventions, acute coronary  revascularization, mechanical circulatory support, and medication should be the same  as in non-pregnant women, irrespective of contraindications.
• The use of non-invasive imaging tests with ionizing radiation during pregnancy should  only be performed when the benefits clearly outweigh the maternal and foetal risk, and  if the result will significantly modify the medical management.
• In women with LQTS and CPVT, the continuation of beta-blockers throughout pregnancy  with monitoring of foetal growth is recommended (atenolol is the only contraindicated  beta-blocker). Beta-blockers of choice are propranolol and nadolol.
• In women with LQT2, post-partum is a distinct high-risk period, and therefore full dosage  of beta-blockers is strongly recommended.
• Genetic testing should be considered in PPCM.
• In women with PPCM and DCM, subsequent pregnancy is not recommended if LV  function does not normalize.
• Genetic testing in women with aortic disease wishing to conceive is recommended and management should be based on the presence and type of P/LP variant.
• Women with the following ACHD lesions should be provided with expert counselling and education by a Pregnancy Heart Team, with clear and thorough discussion of the very high pregnancy risk and the need for a shared decision-making process:
• Systemic RV, in NYHA class III–IV, ventricular dysfunction (EF <40%), more than moderate TR, or treated HF;
• A Fontan circulation and oxygen saturation <85%, reduced ventricular function, severe arrhythmias, or in NYHA class III–IV.
• There is no safe cut-off value for elevated pulmonary artery pressure in pregnancy.
• Women of childbearing potential with PAH should be counselled at the time of diagnosis  about the risks and uncertainties associated with becoming pregnant.
• Any suspicion of VTE, including DVT and PE, requires an immediate formal assessment with validated diagnostic tests by a multidisciplinary specialized team.
• LMWH is the agent of choice for prophylaxis and treatment of VTE in pregnancy.
• When treating women with HF during pregnancy, it should be noted that several drugs [ACE-Is, ARBs, direct renin inhibitors, sacubitril–valsartan (ARNIs), MRAs, and SGLT2 inhibitors] are not recommended. When inotropes or more advanced treatment is necessary, referral to an expert centre is recommended.
• When possible, mechanical valves should be avoided in girls and women of childbearing age.
• Methyldopa, labetalol, and CCBs are recommended for the treatment of hypertension in pregnancy.
• Women at high or moderate risk of pre-eclampsia should be advised to additionally take 75–100 mg of ASA daily from weeks 12 to 36/37.
• After cardiac transplantation, it is recommended to postpone pregnancy for at least 1 year, taking individual risk factors into account.
• Women with APOs should be informed about long-term risks and preventive strategies and offered appropriate follow-up, including psychosocial support (if necessary).

Interpretation:
The “Essential Messages” section emphasizes that the management of cardiovascular disease during pregnancy has shifted from individual physician-based decision-making to a structured multidisciplinary approach. The concept of a Pregnancy Heart Team underscores the need for systematic preconception risk assessment, treatment optimization, medication adjustment, and delivery planning for all women in mWHO class II or higher, extending through the postpartum period. This approach is not only clinical but also ethical, as the guidelines highlight shared decision-making and respect for maternal autonomy. In very high-risk scenarios such as mWHO class IV, pregnancy is medically discouraged, yet the decision must be made in a transparent dialogue with the patient, including the option of pregnancy termination when appropriate. Additionally, the guideline reinforces that vaginal delivery remains the preferred mode in most cases, and life-saving interventions — including defibrillation, interventional procedures, coronary revascularization, or mechanical circulatory support — should not be delayed and must be applied in the same manner as in non-pregnant women.

Limitations
Pre-pregnancy counselling and evaluation

• Data on the adverse effects of assisted reproductive treatment in women with CVD are lacking.

Diagnostic methods

• There is a lack of data on the safety of echocardiographic contrast agents during pregnancy or lactation.
• There are controversial data on the use of gadolinium-based contrast agents in pregnancy.
• There are no clear cut-offs for NT-proBNP levels during pregnancy.
• There are no normative values of cTnI and cTnT in pregnancy and the post-partum period.
• There is a lack of data on normal lung ultrasound pattern during pregnancy.

Drugs during pregnancy and lactation

• Safety data of DOACs and antidotes (idarucizumab, andexanet alfa, cirapantag) in pregnancy are lacking.
• Safety data of newer anti-arrhythmic drugs and rate-controlling drugs (vernakalant, ivabradine, landiolol) in pregnancy are lacking.

Cardiomyopathy and primary arrhythmia syndromes

• The available data on gene-specific management during pregnancy in different cardiomyopathies and primary arrhythmia syndromes are limited.

Peripartum cardiomyopathy

• The potential for recovery of cardiac function in PPCM remains unclear and the risks in subsequent pregnancies are not well defined.

Aortopathies

• More data are needed to correctly estimate the pregnancy risk in women with previous aortic dissection and/or aortic root surgery.
• Risk factors for aortic dissection in the post-partum period are poorly understood, making counselling about this difficult.
• It is unclear whether a distinction between root and ascending phenotype in women with BAV should lead to a different threshold for prophylactic surgery (as in nonpregnant women).

Congenital heart disease

• More data are needed to estimate the risk and the long-term effects of pregnancy (including multiple pregnancies), especially in women with a Fontan circulation or univentricular hearts.
• Risk factors for the development of heart failure and arrhythmias in pregnant women with (systemic) right-heart failure are poorly understood.

Pulmonary hypertension

• Defining the optimal timing to start or escalate PAH therapies in pregnancy complicated with PAH remains challenging.

Venous thromboembolism

• Data on risk stratification of VTE in pregnancy are limited, specifically in those with other pre-existing comorbidities.
• Data on the use of anticoagulant agents (other than LMWH) are limited, just as data on the efficacy and safety of inferior vena cava filters and catheter-based thrombectomy (in PE).

Acquired heart disease

• The foetal risks associated with the newer HF medications remain unclear, particularly regarding exposure during different trimesters.
• The optimal tools to stratify risk of recurrence for atherosclerotic and SCAD ACS are unknown.
• Physiopathological mechanisms of SCAD in pregnancy are unknown.
• Optimal treatment of SCAD during pregnancy is not well established.
• There is scarce evidence about the necessity of using statins during pregnancy in women with cardiovascular risk or established ASCVD.
• Optimal anticoagulation strategies for women with MHVs during pregnancy remain uncertain.
• The role of anti-factor Xa level monitoring needs to be determined.

Women’s Heart Clinics

• Optimal strategies for surveillance and follow-up of women with APOs are unclear.
• It is unclear how social determinants of health (the environmental factors that affect how people live, learn, and work) affect APOs.
• There is a need for studies exploring models of post-natal care, starting from the initial antenatal visit through to the end of the post-partum period.
• Further research is needed to identify risk factors for pregnancy-related depression and poor health behaviour engagement in women with CVD, enabling the development of tailored interventions to improve their health and quality of life.

Commentary:
In contrast, the “Gaps in Evidence” section reveals that despite strong recommendations, substantial scientific uncertainties persist. Critical areas lacking robust data include the establishment of pregnancy-specific reference ranges for cardiac biomarkers such as NT-proBNP and troponins (cTnI, cTnT), as well as the safety of echocardiographic contrast agents, gadolinium-based contrast media, DOACs, and newer heart failure or anti-arrhythmic therapies during pregnancy. Moreover, in peripartum cardiomyopathy, the likelihood of complete myocardial recovery and the true risk associated with subsequent pregnancies remain poorly defined. Evidence is similarly insufficient for complex conditions such as Fontan circulation, systemic right ventricular failure, aortopathies, and pulmonary arterial hypertension, particularly regarding long-term maternal outcomes and management strategies. These gaps indicate that several guideline recommendations are still based on expert consensus rather than high-quality prospective trials, highlighting the urgent need for multicentre, longitudinal research to strengthen future clinical practice and guideline development.