BACKGROUNDArrhythmogenic Right Ventricular Cardiomyopathy (ARVC) presents diagnostic challenges and significant clinical burden due to life-threatening ventricular arrhythmias, compounded by the limited ability to predict patient prognosis using current clinical parameters. MicroRNAs (miRNAs) offer potential as markers in cardiac diseases, including ARVC, providing insights into disease pathogenesis, identification, and prognosis. However, current diagnostic criteria lack sensitivity and specificity, highlighting the need for novel markers like miRNAs to better understand ARVC's complex pathophysiological mechanisms.OBJECTIVEThis multi-site study assessed circulating miRNA expression in ARVC patients, stratified by five-year event-free survival risk, to explore their potential as a marker for improving ARVC diagnosis and prognosis.METHODSBlood samples from 102 ARVC patients, 24 Brugada Syndrome (BrS) patients, and 22 healthy controls were analyzed for the expression of 20 miRNAs using TaqMan quantitative real-time PCR, ARVC patients were stratified by five-year event-free survival risk. Six candidate miRNAs were selected for further analysis, and machine learning algorithms were applied for classification and risk stratification based on miRNA profiles. Additionally, genotyping and functional annotation of miRNA targets were performed.RESULTSSix miRNAs exhibited differential expression between high and low-risk ARVC patients. MiR-15a-5p, miR-16-5p, and miR-92a-3p demonstrated the best performance in risk stratification. MiR-15a-5p also displayed higher expression in patients with adverse cardiac events. Comparative analysis with BrS patients and healthy controls consistently demonstrated increased expression of these miRNAs in ARVC.CONCLUSIONThis study highlights miRNAs' potential to enhance the diagnosis disease progression, and clinical outcomes of ARVC, supporting further research to improve patient care.