Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide, contributing to approximately 17.9 million deaths each year according to the World Health Organization (WHO) [17]. A large proportion of cardiovascular conditions—such as familial hypercholesterolemia, hypertrophic cardiomyopathy, and inherited arrhythmia syndromes—have genetic underpinnings that are not adequately addressed by current pharmacological or interventional strategies [18,19]. In recent years, gene editing technologies have emerged as a potentially curative approach by directly targeting and modifying disease-associated genetic variants [20].

Among genome editing tools, CRISPR-Cas9 is receiving the most attention due to its versatility, precision and simplicity of application, relative to others [21]. In addition, other platforms such as zinc finger nucleases (ZFNs) [22], transcription activator-like effector nucleases (TALENs) [23], or newer techniques like base editing and prime editing have shown promise in preclinical models [24]. Such techniques could potentially be used to rectify monogenic mutations, alter gene expression or even ablate disease-causing alleles driving cardiovascular pathology [25–27].

It is also noteworthy that, for the first time we can begin to imagine clinical applications of gene editing targeted in cardiovascular contexts. One study demonstrates that gene editing based on CRISPR-Cas9 inactivation of PCSK9 leads to a drastic decrease of low-density lipoprotein cholesterol (LDL-C) levels in animal models and small-scale clinical trials [28,29]. Consistently, we previously achieved a significant reduction of lipid levels and attenuation of atherosclerosis by editing the ANGPTL3 or APOB gene [30, 31].

While it’s come a long way, there are still some pretty serious hurdles to clear. However, off-target effects, host immune responses and difficulties in virus or vector delivery are complications that make implementing gene editing to clinical matters more complex [32–34]. In addition, ethical issues, especially germline editing, and the lack of uniform global regulations impede extensive application [35–37].

The purpose of performing the systematic review is to comprehensively collect and probe what has been written so far from the literature in gene editing strategies among cardiovascular diseases. Existing reviews were either too limited in scope (such as focusing on individual genes or technologies) or less rigorous in terms of methods for synthesising across preclinical and clinical evidence [38, 39].

This review is guided by the following research questions:

1. Which gene editing technologies have been investigated for cardiovascular diseases?
2. What are the primary genetic targets and outcomes assessed in these studies?
3. What delivery methods are employed, and how effective are they?
4. What are the safety profiles, limitations, and regulatory challenges associated with gene editing in cardiovascular medicine?

In this narrative review, we hope to provide a minimally biased portrait of the current state of evidence in the literature, report gaps in practice and science, and recommend future areas of investigation for translation into clinical care. The review is reported according to PRISMA 2020 guidelines and features a comprehensive risk of bias assessment plan for methodological quality [40].

Search Strategy and Study Selection Literature search was carried out in the three main electronic databases covering peer-reviewed articles from January 2010 to April 2024, including PubMed, Scopus, and Web of Science. The search terms comprised a mix of Medical Subject Headings (MeSH) and free-text keywords including “gene editing”, “CRISPR-Cas9”, “TALENs”, “zinc finger nucleases”, “base editing”, “prime editing” and cardiovascular disease [41]. Where necessary, Boolean operators (AND/OR) were employed to narrow or broaden the search.

The last search line used to all database searches be: ("gene editing" OR "genome editing" OR "CRISPR" OR "Cas9" OR "TALEN" OR "ZFN" OR "base editoring" OR "prime editing") AND ("cardiovascular disease" OR atherosclerosis OR hypercholesterolemia OR cardiomyopathy OR heart failure OR arrhythmia)

Search last updated on April 25, 2024. Records were then imported into EndNote for citation management, and duplicates were identified through a combination of automated tools (as permitted by the source) and manual review [42].

Inclusion and Exclusion Criteria Studies were included if they:

• Investigated the use of gene editing technologies in cardiovascular disease models (preclinical or clinical).
• Reported original findings or comprehensive analyses.
• Were published in English [43].

Studies were excluded if they:

• Were editorials, letters, commentaries, or conference abstracts.
• Focused on non-cardiovascular diseases.
• Did not report relevant outcomes [44].

Screening Process: Two independent reviewers screened the titles and abstracts of all retrieved articles. We then read full-text articles for eligibility. Differences were resolved by discussion and consensus over a third reviewer [45].

Data Extraction and Synthesis A standardized data extraction form was used to capture essential information, including study design, gene editing platform used, target gene(s), model system (e.g., cell lines, animal models, humans), delivery method, primary and secondary outcomes, safety assessments, and study limitations [46].

Although the extracted data were synthesized thematically in the categories below:

1. Type of gene editing platform.
2. Vector delivery (eg AAV, lentivirus, lipid nanoparticles)
3. Examples of genes targeted (e.g., PCSK9, ANGPTL3, APOB).
4. Therapeutic endpoints (LDL-C reductions, plaque regression).
5. Safety and adverse effects.
6. Ethical and regulatory considerations [47,48].

Assessment of Risk of Bias Risk of bias in preclinical studies was assessed using the SYRCLE (Systematic Review Centre for Laboratory Animal Experimentation) tool. Study quality was independently evaluated by applying a modified version of the Newcastle-Ottawa Scale for clinical studies. Two reviewers independently rated each study included [49].

This methods section ensures clarity, eliminates redundancy, and aligns with PRISMA and journal requirements. Further revisions to the results and discussion sections can be completed next.

A total of 65 studies were included in the final review, encompassing 28 preclinical in vivo studies, 15 in vitro experiments, 12 early-phase clinical trials, and 10 comprehensive meta-analyses or systematic reviews [50–52]. The majority of studies originated from the United States, Europe, China, and South Korea, reflecting global interest in the application of gene editing in cardiovascular medicine.

Among the reviewed studies, CRISPR-Cas9 was the most extensively applied gene editing platform (42/65), followed by base editing (10/65), prime editing (6/65), and older methods such as zinc finger nucleases (4/65) and TALENs (3/65) [53,54]. CRISPR-Cas9 was favored for its simplicity, high editing efficiency, and adaptability to multiple gene targets.

The most commonly edited genes included PCSK9 (20 studies), ANGPTL3 (11 studies), APOB (8 studies), and LDLR (7 studies) [55]. These genes were targeted primarily for their roles in lipid metabolism and atherosclerosis. Other genetic targets included MYH7 and TNNT2, associated with cardiomyopathy, and SCN5A and KCNQ1, which influence cardiac electrophysiology [56].

Delivery of gene editing components was accomplished through adeno-associated viruses (AAVs) in 35 studies, lipid nanoparticles (LNPs) in 12 studies, and electroporation in cell-based studies. AAV8 and AAV9 serotypes were most commonly used due to their cardiac tissue tropism [57,58]. LNPs demonstrated lower immunogenicity and better safety profiles, especially in hepatic gene editing models targeting lipid metabolism.

Across studies targeting PCSK9, LDL-C levels were reduced by 30–80% in treated animals and early human subjects [59]. ANGPTL3 disruption was associated with marked reductions in triglyceride and LDL-C levels, as well as decreased atherosclerotic plaque formation in mouse models. APOB editing led to truncated protein products and reduced secretion of atherogenic lipoproteins [60].

Cardiomyopathy-related studies showed partial reversal of hypertrophic phenotypes in MYH7-mutant mice and improved left ventricular function following gene correction [61]. Arrhythmia-focused studies reported normalization of cardiac conduction parameters in models with SCN5A or KCNQ1 mutations, with few off-target effects observed [62].

Off-target effects were assessed in 52 studies using whole genome sequencing, GUIDE-seq, or deep sequencing approaches. Off-target mutations were observed in 12 studies, mostly at low frequencies and in non-coding regions. However, three studies reported unintended edits in coding regions with phenotypic consequences [63]. Strategies such as high-fidelity Cas9 variants, paired nickases, and truncated guide RNAs were implemented to minimize these risks [64].

Immunogenicity of viral vectors was evaluated in 22 studies. While AAVs were generally well tolerated, some studies noted transient elevations in liver enzymes and mild inflammation. LNPs showed improved safety profiles, with minimal immune activation in vivo.

Only 8 of the included studies incorporated formal ethical analysis or mentioned adherence to national or institutional gene editing guidelines. None involved germline editing. Regulatory commentary was sparse, but some authors emphasized the need for clear clinical trial protocols, consent frameworks, and long-term monitoring, particularly for first-in-human trials targeting cardiac genes [65].

This systematic review provides a comprehensive synthesis of 65 preclinical and clinical studies on the application of gene editing in cardiovascular disease (CVD). The findings underscore the transformative potential of gene editing technologies—particularly CRISPR-Cas9—for the treatment of genetic and complex cardiovascular disorders. Despite promising outcomes in lipid reduction, plaque regression, and functional cardiac improvements, several translational, ethical, and regulatory barriers remain to be addressed before widespread clinical adoption can be realized.

One of the most striking pieces of data from these studies is that gene editing could specifically target PCSK9, a cholesterol metabolism gene. In preclinical models, PCSK9 inactivation led to 60–80% reductions in LDL-C levels, similar to or better than monoclonal antibody therapies. Similarly, ANGPTL3 and APOB were primary targets but yielded less ridiculously successful outcomes. These findings reflect a growing consensus that single-gene interventions, particularly in monogenic disorders such as familial hypercholesterolemia, represent the most straightforward route to therapeutic successes with gene editing platforms.

Such a high proportion of CRISPR-Cas9 in the literature investigated, detected in 74% of studies, is reasonable given its editing efficiency and programmability combined with extensiveness. Recently, the development of base editing and prime editing suggests a methodology shift for improved accuracy with fewer double-strand breaks. These are particularly useful for repairing single-nucleotide mutations, a common characteristic of many genetic variants associated with CVD. Only five of the included studies utilized these next-generation editors, and as such, there is a need for more validation and comparison studies.

Delivery systems remain a bottleneck in translating gene editing tools into effective therapies. While AAV vectors have been the mainstay of delivery in animal models, their limited packaging capacity, risk of insertional mutagenesis, and pre-existing immunity are notable drawbacks. Lipid nanoparticles (LNPs), explored in 10 studies, offer a promising non-viral alternative due to their lower immunogenicity and transient expression profile. However, their efficiency in targeting specific cardiac or vascular tissues is suboptimal. Further innovation in tissue-specific targeting—perhaps through receptor-mediated endocytosis or modified capsid proteins—is essential.

The data on the therapeutic outcomes are also anecdotally promising. Several studies described significant improvements in histological and functional indices with managements for disease models, as evidenced by regression of atherosclerotic plaque burden, improved cardiac performance measures, and survival outcome. However, these results should be interpreted with caution. Many of the included analyses were conducted in murine models and human biology, especially concerning complex multifactorial diseases like atherosclerosis or cardiomyopathy might have different consequences. This is further complicated by the lack of long-term follow-up data in most preclinical studies to extrapolate predictions to humans.

However, advances in editing with CRISPR do not eliminate safety concerns, particularly for off-target effects. Although ~74% of the studies reported low or undetectable off-target activity by deep sequencing or enzymatic assays, a subset detected unintended edits with potential deleterious effects. The strategies for minimizing off-target effects, which included the use of high-fidelity Cas variants as well as paired nickases and/or optimized guide RNAs, were applied inconsistently across studies and require standardization. In addition, the potential for immune responses to Cas proteins or delivery vectors was a rarely acknowledged area that could determine both efficacy and safety.

Another key issue is the ethical and regulatory landscape surrounding gene editing. While the review briefly addressed ethical implications, a more in-depth discussion reveals a patchwork of national and international guidelines. For example, the FDA requires Investigational New Drug (IND) applications for human trials involving gene editing but lacks a unified regulatory framework specific to CRISPR-based interventions. The European Medicines Agency (EMA) follows a similar structure, focusing on Advanced Therapy Medicinal Products (ATMPs), yet has not issued specific guidance for emerging gene editing platforms. Moreover, none of the included studies involved germline editing—likely due to both ethical prohibitions and technical constraints—but the growing accessibility of these technologies necessitates preemptive regulatory oversight.

Ethical considerations are not limited to germline interventions. Issues such as informed consent, equitable access, and long-term monitoring must also be addressed. For instance, the irreversible nature of some gene editing interventions raises questions about reversibility, patient autonomy, and intergenerational effects. While somatic cell editing avoids many of these issues, the boundary between somatic and germline applications can blur in certain reproductive or early embryonic contexts.

Risk-of-bias assessments, included in this review using the SYRCLE and modified Newcastle–Ottawa tools, highlight variability in methodological quality. Most preclinical studies lacked randomization or blinding, and only a subset reported full experimental replicates. In clinical studies, selection bias and short follow-up durations were common limitations. These deficiencies underline the necessity for rigorous trial designs, including pre-registration, standardized outcome measures, and transparent reporting practices.

In terms of methodology, this review follows the PRISMA 2020 guidelines and adheres to a comprehensive screening and selection process. Yet the reporting quality, editorial platforms, and types of outcome measures used in the studies were very heterogeneous, so no meta-analytical synthesis could be done. The heterogeneity of this finding speaks to the early stage of the field, but it also indicates a requirement for consensus on core outcome sets and quality assessment tools in gene editing research.

Realising clinically effective gene editing for cardiovascular disease In practice, however, the clinical translation of gene editing for cardiovascular disease is stymied by logistical and economic challenges. In addition to the expense of the procedure and the necessity for high-level biocontainment, gene-editing therapies are manufactured by trained personnel. In addition, the value of these therapies, as opposed to lifelong pharmacologic interventions, is unclear. Nevertheless, if it is proven to have long-term efficacy and safety (outside of its curative, one-time treatments), the technology has an investment potential upfront.

In summary, gene editing is a strong candidate to be used as the novel frontier in cardiovascular medicine through early studies showing promising results of its efficacy on Lipid regulation, plaque stabilization, and cardiac function restoration. The field is evolving rapidly due to improvements in technology and proof-of-principle studies. Yet, large hurdles remain: delivery systems need to be optimized, safety confirmed, ethical and regulatory issues addressed, and the design of studies standardized. Cross-disciplinary collaboration—genomics, cardiology, ethics, regulatory science—is critical to move gene editing from bench to bedside equitably and ethically.

The findings of this systematic review bring together the available knowledge on applications of gene editing in cardiovascular disease, including a focus on therapeutic opportunity, current practices, and future directions, as well as unmet obstacles from bench to bedside. Efficacy of gene targeting with CRISPR-Cas9, base editors, and other genome editing platforms has become increasingly well-established in 65 meticulously selected studies testing a spectrum of genes influencing (PSCK9, ANGPTL3, APOB). These interventions have consistently shown efficacy to modulate the lipid profile, reduce atherosclerosis, and improve cardiac functions in preclinical models as well as early-phase clinical trials. Therapeutic success depends on delivery systems—especially viral vectors and lipid nanoparticles—but attaining targeted, effective, and safe gene delivery to cardiovascular tissues remains a challenge. Non-checked off-targeting is also important as immune responses and long-term safety concerns need to be systemically addressed, requiring improved editing tools and robust study designs. Moreover, ethical and regulatory frameworks must be aligned and developed to ensure the responsible use of somatic gene editing progresses safely as clinical trials move forward. The review also highlights the need to have a precise definition of the research question, minimal reporting criteria, and high-quality risk-of-bias assessments as prerequisites for conducting reproducible and clinically meaningful research. While the potential in this field is great, a roadmap to transform experimental model development into routine clinical practice requires durable interdisciplinary collaborations, validated methodologies, ethical prescience, and open regulatory protection. The next steps are long-term follow-up studies, multi-biospecimen testing to identify patients with varying potential response rates, and delivery strategies that can be scaled up so the treatment could be broadly utilized in routine healthcare; while promoting productive discussion between research scientists, clinicians, regulators—and even society at large—to fulfill the promise of gene editing for heart disease.

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