Lactylation in cardiovascular disease: mechanisms and therapeutic potential

Abstract Lactate, traditionally regarded as a metabolic byproduct, has recently been recognized as a critical signaling molecule and an epigenetic regulator through the post-translational modification known as lactylation. Lactylation links cellular metabolic states to gene transcription by modifying lysine residues on histone and non-histone proteins, thereby influencing inflammation, immune responses, fibrosis, angiogenesis and energy metabolism. Emerging evidence demonstrates that lactylation plays pivotal roles in cardiovascular diseases (CVDs), including atherosclerosis, ischemic heart disease, heart failure and cardiomyopathies. Lactylation orchestrates macrophage polarization, endothelial dysfunction, vascular smooth muscle cell phenotypic switching, cardiomyocyte metabolic remodeling and immune cell activation, ultimately shaping disease initiation and progression. Moreover, lactylation exhibits context-dependent dual effects: promoting reparative processes such as inflammation resolution and tissue healing, while also driving pathological remodeling, fibrosis, mitochondrial dysfunction and maladaptive immune activation. Advances in analytical techniques including LC-MS/MS, lactylation-specific antibodies, and metabolic flux analysis have enabled comprehensive profiling of lactylation dynamics in cardiovascular tissues. Given its central role in metabolic–epigenetic crosstalk, targeting lactylation and its regulatory enzymes represents a promising therapeutic strategy for modulating cardiac injury, remodeling and repair. This review summarizes the molecular basis, cellular functions, pathological implications and therapeutic potential and limited of lactylation in CVDs, providing new insights into its translational value for cardiovascular medicine.