RNA Processing in Cardiac Hypertrophy: Coordinating Physiological Adaptation and Pathological Remodeling

Cardiac hypertrophy represents a complex remodeling process involving extensive reprogramming of gene expression. While transcriptional regulation has been well characterized, post-transcriptional RNA processing has recently emerged as a crucial determinant of cardiac homeostasis. This review summarizes current knowledge of RNA modifications, alternative splicing, mRNA stability, and RNA editing in physiological and pathological hypertrophy. We highlight key epitranscriptomic marks such as N6-methyladenosine (m⁶A), 5-methylcytosine (m⁵C), and 7-methylguanosine (m⁷G), as well as the functions of RNA-binding proteins and adenosine deaminases acting on RNA (ADAR1/2). In exercise-induced hypertrophy, RNA processing contributes to adaptive remodeling by supporting sarcomere organization, calcium handling, and survival pathways, exemplified by RBFOX2-dependent splicing of CACNA1C, RBM20-directed regulation of titin isoforms, and METTL14-mediated m⁶A signaling that enhances Akt activity. Conversely, pathological stress leads to dysregulated RNA programs that promote maladaptive remodeling through aberrant splice variants, perturbation of circular RNAs, and persistent pro-inflammatory signaling, thereby facilitating contractile dysfunction and progression to heart failure. Context-dependent regulators, including METTL3, YTHDF2, RBM24, and ADAR2, orchestrate the balance between adaptive and maladaptive responses. Targeting specific nodes, such as METTL3-driven m⁶A methylation or RBM24-dependent splicing fidelity, may provide innovative therapeutic strategies. Advances in RNA-targeted interventions, including ADAR-mediated editing and small molecule inhibitors of methyltransferases, highlight the translational potential of RNA processing as a novel avenue for precision cardiovascular therapy.