The ‘Ten Commandments’ for the 2025 ESC Guidelines on Cardiovascular Disease and Pregnancy

The concept of ‘Ten Commandments’ historically evokes a rigid, hierarchical—and often exclusionary—framework. In clinical care, especially in the context of pregnancy and cardiovascular disease (CVD), such an approach risks oversimplifying complex, personal decisions. This reimagined set of ‘commandments’ does not aim to dictate, but to guide. They are based on the 2025 ESC Guidelines on Cardiovascular Disease and Pregnancy.1 It draws from current evidence, expert consensus and, most importantly, the principle of shared decision-making. These guiding principles aim to promote safety, equity, and respect for autonomy, recognizing the diverse lived experiences and preferences of women navigating pregnancy with cardiovascular disease. Figure 1 illustrates the basic concepts of managing CVD in pregnancy, highlighting the central role of the woman and the importance of pregnancy Heart Team–based care tailored to the underlying disease, spanning all stages from pre-conception to long-term follow-up: Start early, think long-term—and integrate genetics: pre-conception counselling and post-partum follow-up are essential for women with CVD, especially after adverse outcomes. Women with known or suspected heritable cardiovascular disorders should receive timely genetic counselling, including discussion of reproductive options and gene-specific management (e.g. in heritable thoracic aortic disease, cardiomyopathies, and primary arrhythmia syndromes). Refer wisely to a Pregnancy Heart Team and keep the woman central in all decisions: the Pregnancy Heart Team plays a pivotal role in the care of women with modified World Health Organization (mWHO) 2.0 ≳ Class II–III risk, offering individualized management and delivery plans. Women in Class I–II generally do not require referral. In all cases, shared decision-making should be the standard. The woman’s autonomy must be respected, and tailored counselling—including psychosocial support—should be provided, particularly in high-risk scenarios such as mWHO 2.0 Class IV. Optimize drug therapy before and during pregnancy: various drugs are contraindicated in pregnancy or lack safety data, which requires optimization of drugs of choice during pregnancy. Contraindicated drugs include—but are not restricted to—direct oral anticoagulants (DOACs), several heart failure drugs, some anti-arrhythmic drugs, and some immunosuppressants which must be adjusted accordingly. Recognize and manage hypertensive disorders early: hypertensive disorders of pregnancy are among the most common and high-risk complications in pregnancy. Women with pre-existing or pregnancy-induced hypertension should receive tailored care, including lifestyle advice, blood pressure monitoring, and appropriate antihypertensive therapy (e.g. methyldopa, labetalol, or calcium channel blockers). In women at moderate to high risk of pre-eclampsia, low-dose aspirin (75–100 mg) from week 12 to 36/37 is recommended as a preventive measure. Repeated testing for pre-eclampsia should be performed including clinical examination, proteinuria, and blood sampling. BP ≥160/100 in a pregnant woman is an emergency requiring hospitalization. Choose valves with pregnancy in mind: in young women requiring valve replacement, biological prostheses are preferred. No anticoagulation regimen for mechanical valves is truly safe in pregnancy, and decision-making should be individualized, taking healthcare system factors into account. Tailor care in congenital heart disease: the growing number of women with complex congenital heart disease reaching reproductive age requires personalized management. Vaginal delivery remains the preferred mode in most, but care must be adapted to the underlying lesion and risk profile. Do not delay life-saving interventions: in life-threatening situations, diagnostic and therapeutic strategies should mirror those in non-pregnant patients. This includes imaging, defibrillation, coronary angiography and stenting, as well as mechanical circulatory support—with special attention to pregnancy-specific differential diagnoses such as spontaneous coronary artery dissection, pulmonary embolism, and aortic dissection. Manage arrhythmias proactively: arrhythmias may worsen or emerge during pregnancy. Cardioversion can be performed when indicated, and when using anti-arrhythmic drugs those contraindicated during pregnancy should be avoided. Continuation of beta-blockers is generally advised, especially in inherited arrhythmia syndromes. Do not miss peripartum cardiomyopathy: in any case of heart failure during late pregnancy or post-partum, consider peripartum cardiomyopathy. Prompt treatment is critical and may include bromocriptine. A subsequent pregnancy should be avoided if LV function does not recover. Genetic testing is recommended. Follow inherited cardiomyopathies and channelopathies closely: many women with cardiomyopathies or primary arrhythmia syndromes tolerate pregnancy well with close monitoring and appropriate therapy. However, women with obstructive hypertrophic cardiomyopathy or with long QT syndrome, Type 2 require special care before, during, and after pregnancy due to their elevated risk profile. Role of the Pregnancy Heart Team in managing cardiovascular disease and pregnancy Nothing to declare.