Heart failure in pregnancy: where the 2025 ESC Guidelines ‘cardiovascular disease and pregnancy’ illuminate—and where shadows remain

Heart failure (HF) remains the leading cardiovascular cause of maternal morbidity and mortality worldwide. The 2025 ESC Guidelines for the Management of Cardiovascular Disease and Pregnancy.1 represent a pivotal update, reframing pregnancy in women with HF from a high-risk contraindication towards a condition that, in selected cases, can be safely managed through structured, multidisciplinary care. Importantly, the document introduces not only refinements in antenatal management but also a paradigm shift toward post-pregnancy cardiovascular risk assessment and long-term surveillance, particularly following adverse pregnancy outcomes. This evolution is particularly relevant for women with pre-existing HF, cardiomyopathy, or peripartum cardiomyopathy (PPCM), where recent registry and trial data have begun to illuminate both progress and persistent uncertainty.2 A major novelty of the 2025 ESC Guidelines (Figure 1) is the formal integration of long-term cardiovascular care following pregnancy, especially after adverse pregnancy outcomes such as pre-eclampsia, gestational hypertension, or fetal growth restriction.1 From a public health perspective, this represents a substantial advance, as the guidelines now recommend structured cardiovascular risk assessment approximately 3 months postpartum, with implications for lifelong prevention strategies.