The European Society of Cardiology (ESC) released a series of new cardiovascular guidelines in August 2025, including its 107-page guidance on the management of cardiovascular disease and pregnancy.1 This update of the 2018 guidelines has not only expanded on the various cardiovascular risk classes, but also added sections, specifically on the management of arrhythmias, acquired heart disease, such as ischaemic heart disease, and other areas including cardiomyopathy and various types of aortopathies.2
For busy cardiologists in the Asia-Pacific region who care for women with heart disease during their pregnancy, these extensive guidelines are much appreciated; they result from findings reported through research and international registries over the past 6–7 years. Nonetheless, some of the guidelines are also challenging to implement, as a greater emphasis is now placed on having a multidisciplinary pregnancy heart team (PregHT) in place to give pre-conception counselling and to provide comprehensive assessments and care during pregnancy, delivery and the postpartum period. Managing women with cardiovascular disease during their pregnancies is no longer the domain of cardiologists or obstetricians alone.
Well-established, multidisciplinary PregHTs – consisting of a core group of cardiologists, obstetricians, anaesthesiologists, midwives and clinical nurse specialists and an extended group including neonatologists, geneticists, intensivists, primary care physicians and social workers – are somewhat lacking across the Asia-Pacific region, and the publication of this guideline may help to spur the establishment of such services across the region.
Key Changes and Recommendations
WHO Risk Classification
The second version of the modified WHO (mWHO) cardiovascular risk classification (mWHO 2.0) is a refined and expanded version of the 2018 mWHO risk classification with new clinical categories (e.g. ventricular dysfunction, arrhythmias, cardiomyopathy, coronary artery disease and valvular heart disease), which makes it easier to classify patients into the correct risk classes.
This is particularly helpful during pre-conception counselling and subsequently in deciding the frequency and level of care as well as the extent of follow-up needed during pregnancy. All women with cardiovascular disease should have personalised pregnancy-related risk assessments before and during pregnancy. Cardiologists in the Asia-Pacific region who look after women of childbearing age should be familiar with the mWHO 2.0 cardiovascular risk classification and refer patients in risk classes II–III, III and IV to the nearest PregHT for pre-conception counselling.
Shared Decision-making
The 2025 guidelines put a new emphasis on shared, individualised decision-making, taking into consideration the patient’s autonomy, perspectives and values together with input from the PregHT. This is particularly pertinent for pregnant women in mWHO 2.0 risk classes II–III, III and IV in respecting their decision to have a family and moving away from blanket advice to avoid pregnancy or have a termination, even in those with the highest-risk mWHO class IV.
Genetic Testing and Counselling
The 2025 guidelines stipulate that pre-conception genetic testing and counselling, particularly for women with inheritable cardiac conditions such as certain types of aortopathies, channelopathies, cardiomyopathies and congenital heart disease, should be discussed and considered. However, specialised genetic testing centres with the appropriate specialists and counsellors are few and far between in countries across the Asia-Pacific.
Algorithms for Specific Situations
The 2025 guidelines are clinically orientated and practical, with new algorithms for the management of specific clinical situations in pregnant women. These include those for the management of chest pain, hypertension, venous thromboembolism (VTE), pulmonary embolism (PE) and cardiac arrest in pregnancy.
Venous Thromboembolism
Women who are pregnant or in the postpartum period who have suspected VTE (DVT and/or PE) require immediate diagnostic clarification and the involvement of an expert team with prompt initiation of treatment such as therapeutic low molecular weight heparin (LMWH) even before imaging or confirmation of diagnosis.
In pregnant or postpartum women with confirmed VTE but without haemodynamic instability, anticoagulation is recommended using a therapeutic dose of LMWH based on early pregnancy body weight. For women with acute, high-risk PE, a catheter-based reperfusion strategy or systemic thrombolysis should be considered (class IIa).
Valvular Heart Disease
Women of childbearing age with valvular heart disease usually have rheumatic or congenital heart disease. Regurgitant valvular heart lesions are better tolerated than stenotic valvular lesions.
Pre-pregnancy intervention (e.g. percutaneous mitral commissurotomy) should be considered in those with significant mitral stenosis (mitral valve area <1.5 cm2) before pregnancy (class 1) and during pregnancy (class IIa) if symptoms are severe or where pulmonary artery systolic pressure is >50 mmHg despite medical therapy. There is no specific mention of the management of acute rheumatic heart disease, which is more commonly seen in the Asia-Pacific region.
Adult Congenital Heart Disease
The section on pregnant women with adult congenital heart disease is extensive, with major updates from recently published registry studies. Maternal and fetal risks, as well as the degree of monitoring, investigations, management during pregnancy and delivery should be discussed based on the specific underlying congenital lesions.
Important recommendations include respecting the patient’s wish to get pregnant even in very-high-risk patients. For example, in women with a systemic right ventricle (those who have had Mustard, Senning or congenitally corrected transposition of the great arteries), who are in New York Heart Association class III/IV or systemic right ventricular dysfunction (right ventricular ejection fraction <40%) or severe tricuspid regurgitation were previously advised against pregnancy (class IIa, 2018 ESC guideline).2 In the 2025 ESC guideline, this high-risk group of systemic RV patients wishing to get pregnant should be counselled by the PregHT regarding the high risk of pregnancy-related adverse events (class I).1 The decision for pregnancy should be made after counselling with the PregHT.
Arrhythmias Management
Updated guidelines on the management of tachy- and bradyarrhythmias, with specific recommendations on the types of antiarrhythmic drugs, role of catheter ablation in expert centres for refractory and poorly tolerated arrhythmias, device management (pacemakers/ICDs) and ICD shock management during pregnancy are addressed in detail.
Medications
Significant changes in medication use during pregnancy include:
- Clopidogrel is recommended as the P2Y12 inhibitor of choice during pregnancy if dual antiplatelet therapy is required (class I).
- Flecainide, in addition to β-blockers, should be considered for long-term AF rhythm control in pregnancy (class IIa).
- β-blocker continuation should be considered during pregnancy in women with cardiomyopathies, with close follow-up of fetal growth (class IIa).
- β-blocker therapy throughout pregnancy and in the postpartum period is recommended in women with Marfan syndrome and other heritable thoracic aortic diseases (class 1).
- Blood pressure medications: methyldopa, labetalol, metoprolol and dihydropyridine calcium channel blockers are recommended for the treatment of hypertension in pregnancy (class I).
Anticoagulation and Mechanical Valves
The guidelines state that mechanical valves should not be implanted in girls and women of childbearing age. However, there is a stronger recommendation to continue warfarin (class IIa) in women who already have mechanical prosthetic heart valves and are at a higher thrombosis risk (e.g. mitral or right-sided valves) during the second and third trimester up to week 36 of gestation. International normalised ratio monitoring is recommended weekly or at a minimum of every 2 weeks.
The use of LMWH during the second and third trimester, with anti-factor Xa level monitoring for women with mechanical valves at a lower risk of thrombosis, is now relegated to class IIb. Direct oral anticoagulants are not recommended during pregnancy (class III).
Special Populations
Recommendations for the management of patients after heart transplantation on immunosuppression include postponing pregnancy until at least 1 year after heart transplantation, with the level and frequency of monitoring of immunosuppression serum drug levels and donor-specific antibodies given in detail.
The care of patients with gestational cancer who require cardiotoxic therapies and pregnancies in cancer survivors requires close discussion and collaboration between the PregHT and cardio-oncology team.
Adverse Pregnancy Outcomes
Adverse pregnancy outcomes (APOs) such as gestational hypertension, pre-eclampsia, gestational diabetes, babies who are small or large for gestational age and pre-term birth are interrelated disorders that share common pathways.
These APOs should be recognised as cardiovascular risk markers; the guidelines recommend documenting the APOs and performing a cardiovascular risk assessment after delivery and incorporating this into the patient’s lifetime cardiovascular risk management.
Women with APOs should be informed about long-term risks and preventive strategies, and offered appropriate follow-up. After delivery, care should be handed over either to the primary care provider, primary cardiologist or women’s heart clinic in the postpartum period for appropriate, individualised cardiovascular risk checks. Cardiovascular risk checks should include blood pressure, glucose, lipids and BMI measurements alongside lifestyle counselling and emotional support for stress.
Asia-Pacific Application
The following steps are proposed to integrate the 2025 ESC guidelines into the Asia-Pacific setting:
- General implementation: internal review and discussion of the guidelines should be carried out and the relevant components adopted in local settings and practice. Team members should be given education and training summarising the changes.
- PregHT: local, regional and national PregHTs to manage pregnant women with a varying complexity of heart conditions should be established. The core and expanded PregHT members should be defined, including their roles and relevant sub-specialities.
- Pre-conception counselling: a structured, documented approach for any woman with known cardiovascular disease should be adopted using the updated mWHO 2.0 maternal cardiovascular risk classification and outcomes during counselling. Shared decision-making should be emphasised and discussions documented. Contraception types and needs should be reviewed. In addition, stopping teratogenic drugs (e.g. angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and sacubitril/valsartan) should be considered before pregnancy.
- Protocols and algorithms: local, regional and national protocols on topics such as anticoagulation for women with mechanical valves, anticoagulation during delivery, and drug therapy during pregnancy and breastfeeding should be reviewed.
- Education and documentation: electronic medical record templates, patient information leaflets and electronic educational resources should be updated to reflect changes in clinical practice and establishment of care.
- Postpartum follow-up and long-term cardiovascular risk management: patients should be informed and educated on their APOs (such as pre-eclampsia, placental abruption, preterm birth and gestational diabetes) and clinicians should ensure the APOs are documented in the patient’s problem list and trigger a cardiovascular risk assessment after birth as per local guidelines. The team (e.g. primary care physician, preventive cardiology team or women’s health clinic) that will manage the related cardiovascular risks postpartum should be decided locally.
Conclusion
The 2025 ESC guidelines for the management of cardiovascular disease and pregnancy are comprehensive, detailed and expanded compared to the 2018 guidelines, with many key messages, tables, figures with algorithms, what to do and what not to do lists, as well as discussion on current knowledge gaps in various sub-topics.
Physicians from the Asia-Pacific regions will need to digest the vast amount of information presented and incorporate the most relevant and pertinent sections into their local clinical practice. The formation and identification of a local core PregHT to look after the interests of pregnant women with heart disease is the first and most crucial step to take.
The true impact of these guidelines on the care of pregnant women with heart disease in the Asia-Pacific region will depend on the rate and scale of adoption of the recommendations. These recommendations are predominantly based on research and data collected from Western populations and, unless we start to gather data, collaborate with international registries (e.g. Registry Of Pregnancy And Cardiac disease [ROPAC]) and publish our own research on Asian populations, we will have to assume for now that these recommendations also apply to most of our local patients.