Mesenchymal stem cell-derived exosomes (MSC-Exo) are a promising nanotherapeutic for cardiovascular diseases due to their ability to promote regeneration, low immunogenicity, and multiple differentiation potential. They have cardioprotective effects, especially by supporting the formation of new blood vessels, inhibiting inflammation, regulating immune reactions, reducing apoptosis and fibrosis. Their efficacy has been demonstrated in seven major cardiovascular indications: myocardial infarction, myocardial ischemia-reperfusion injury, atherosclerosis, heart failure, cardiomyopathy, myocarditis, and pulmonary hypertension. To increase their effectiveness, research is focusing on advanced delivery methods, such as intrapericardial delivery, use of peptides targeting the ischemic myocardium, and functional encapsulation in hydrogels. These strategies improve the retention of exosomes and their bioavailability. The combination of biological mechanisms and engineering solutions makes MSC-Exo a multifunctional platform for regenerative medicine. Optimal delivery systems and precise targeting of exosomes offer new clinical translational potential in the treatment of cardiovascular diseases.