Epigenetics of cardiomyopathies: the next frontier

Cardiomyopathies (CMP) are a diverse group of myocardial diseases that cause structural, functional, and pathological changes to the heart. Alterations at the molecular level associated with the clinical phenotype and progression of CMPs cannot be solely explained by the genetic mutations, even in inherited cardiomyopathies. Epigenetics and environmental factors are likely to significantly modify the clinical manifestations of CMPs, resulting in variable clinical expression and different age-related penetrance. This review examines the role of dysfunctional DNA methylation, histone modifications, chromatin remodelling, and noncoding RNAs in the development and exacerbation of CMPs, highlighting their potential as diagnostic markers and therapeutic targets, including the use of histone deacetylase inhibitors. Additionally, it explores how environmental exposures can influence epigenetic changes and potentially be used for preventive strategies and personalized care in CMP patients. Monozygotic twin studies and intergenerational studies are discussed as valuable tools for understanding the interplay between genetics, epigenetics, and environmental factors. Lastly, this review addresses current challenges and future perspectives, such as the need for greater specificity in epigenetic therapies, minimizing off-target effects, and investigating sex differences in CMP research and treatment.