Extracellular vesicles in cardiovascular diseases: From molecular signatures to therapeutic applications

Cardiovascular diseases (CVDs) remain the leading cause of global morbidity and mortality, emphasizing the need for sensitive biomarkers and effective therapeutic strategies. Extracellular vesicles (EVs) are membrane-bound nanoparticles released by virtually all cell types that mediate intercellular communication through the transfer of proteins, lipids, messenger RNAs, microRNAs and DNA. Increasing evidence indicates that alterations in EV cargo contribute to the initiation and progression of multiple cardiovascular disorders, while also offering opportunities for minimally invasive diagnosis and targeted therapy. This review summarizes current evidence on the molecular mechanisms, diagnostic significance and therapeutic applications of EVs across major cardiovascular diseases, including atherosclerosis, coronary artery disease, myocardial infarction, heart failure, atrial fibrillation, valvular heart disease and cardiomyopathies. Disease-specific EV-associated proteins and non-coding RNAs, particularly microRNAs, are discussed as candidate biomarkers for diagnosis, risk stratification, prognosis and treatment monitoring. The review also highlights emerging EV-based therapeutic approaches, including regenerative medicine, engineered EVs and targeted drug delivery systems, while critically discussing translational challenges such as EV heterogeneity, lack of standardized isolation and characterization protocols, scalability, regulatory considerations and the need for robust clinical validation. Most mechanistic and therapeutic evidence remains preclinical and EV biomarker assays are not yet established for routine care. In conclusion, EVs represent a promising platform for advancing precision cardiovascular medicine by integrating molecular diagnostics with innovative therapeutic strategies. Although substantial progress has been achieved, overcoming current technical, regulatory and clinical challenges through standardized methodologies and large-scale validation studies is essential for translating EV-based technologies into routine cardiovascular practice.