Agent-based simulation and digital twins in heart failure care: Current evidence, validation and implementation barriers.

Heart failure (HF) requires coordinated care across home, ambulatory, emergency, inpatient and hospital-at-home settings. Agent-based models (ABM), discrete-event simulation (DES) and digital twins (DT) have been proposed to support service design and individualized decisions, but their clinical maturity is uncertain. We performed a narrative review, updated through 31 July 2026, separating established clinical evidence for HF care models from HF-specific computational evidence and extrapolated cardiovascular DT literature. The evidence map includes nine representative HF-specific computational studies: four agent-based or hybrid systems, one DES model and four DT-oriented studies. Most were conceptual, simulation-based, retrospective or proof-of-concept; only a small number included external or invasive-reference validation, and none established routine DT-guided clinical care. Current evidence supports ABM/DES mainly for hypothesis generation and service design. HF digital twins remain investigational. Prospective validation, interoperability, recalibration, cybersecurity, workflow integration, cost-effectiveness and digital equity are prerequisites before clinical implementation.