RNA- and protein-based medicines are expanding cardiovascular therapeutic options, but efficient delivery to cardiomyocytes, fibroblasts, vascular cells, and lesional immune cells remains difficult. Target selection also relies disproportionately on European-ancestry datasets, limiting causal resolution and portability. This narrative review evaluates extracellular vesicles (EVs) as carriers and active biological products for cardiovascular RNA and protein therapeutics. We distinguish EVs carrying a defined active ingredient, intrinsically bioactive EV preparations, and EV-inspired synthetic systems. We link delivery design to human multi-omics by integrating diverse-ancestry genome-wide association studies, fine-mapping, molecular quantitative trait loci, colocalization, Mendelian randomization, and single-cell or spatial transcriptomics. Hepatic targets such as PCSK9, LPA, APOC3, ANGPTL3, AGT, and TTR provide benchmarks against which EV platforms can be assessed. The strongest rationale for EVs lies in extrahepatic programs where tissue access limits otherwise compelling myocardial, fibrotic, vascular, or regenerative targets. We propose a stage-gated roadmap connecting causal evidence and cell-state specificity to modality selection, cargo loading, targeting, endosomal escape, biodistribution, human cardiac models, manufacturing, potency, and safety. We then apply the framework to worked examples (LPA, CAMK2D, COL6A3-derived endotrophin, AGER/RAGE, and VEGFA), in which fine-mapping, colocalization, Mendelian randomization, ancestry-specific evidence, and cell-state localization jointly determine the modality and the carrier, including targets for which an EV is not the appropriate choice. Cited delivery studies are graded on a four-level evidence ladder spanning tissue association, intact-cargo delivery, cytosolic release, and pharmacodynamic activity, because most cardiovascular EV reports establish only the lower levels. The cardiovascular EV studies reviewed do not establish clinical benefit or an advantage over optimized lipid nanoparticles at matched active-cargo dose in a cardiovascular disease model. Clinical translation depends on reproducible functional delivery, a defined mechanism, consistent product quality, and meaningful benefit relative to established treatments.