ESC 2026 Heart Failure Guidelines Revise EF Classification, Introduce New Treatment Categories
Reflecting improved understanding and treatment advances, new European Society of Cardiology (ESC) Guidelines on heart failure have been published online today in the European Heart Journal and will be presented at ESC Congress 2026 this afternoon.
Heart failure is not a single disease but a clinical syndrome comprising signs and/or symptoms that are caused by the heart not functioning properly. The prevalence of heart failure is estimated to be 1–3% in the general adult population and although mortality rates have improved considerably over the past three decades, less than 60% of patients diagnosed with heart failure are still alive 5 years later.
“The overall burden of heart failure is expected to rise due to an ageing population and greater prevalence of risk factors and obesity,” said Task Force Chair, Professor Lars Køber from Rigshospitalet - Copenhagen University Hospital, Denmark. “One of the key points we have tried to emphasise in the 2026 guidelines is the importance of prevention and starting treatment as early as possible.” The 2026 guidelines have adopted a staging approach and provide recommendations across the spectrum from preventing heart failure in patients at risk (stage A) to treating advanced heart failure (stage D).
Previously, heart failure was divided into three phenotypes based on left ventricular ejection fraction (LVEF), a measure of the amount of blood the left ventricle pumps out around the body with each heartbeat. The 2026 guidelines have removed the classification of heart failure with mildly reduced ejection fraction (LVEF of 41 to 49%) and now describe two phenotypes: heart failure with reduced ejection fraction, defined as LVEF of less than 50%, and heart failure with preserved ejection fraction, defined as LVEF of 50% or more. Explaining why this change was made, Task Force Chair, Associate Professor Marianna Adamo from University and Civil Hospital of Brescia, Italy, commented: “The mildly reduced LVEF phenotype was introduced in previous guidelines to focus on patients not usually included in clinical trials. However, we know that these patients share similar pathophysiology and benefit from similar treatments as those with reduced LVEF. Thus, we decided to simplify the classification.”
In addition, heart failure was previously described as either ‘chronic’ or ‘acute’, but in another key update, ‘acute’ has been replaced by ‘decompensated’. “This change was made for clarity,” noted Associate Professor Adamo. “In some patients, heart failure does not suddenly get worse but rather, heart function gradually declines to the point where the heart can no longer compensate for its defects.”
The Task Force has also introduced new nomenclature to describe different types of therapies. “The term ‘guideline-directed medical therapy (GDMT)’ was introduced more than 10 years ago,” commented Professor Køber. “However, there have been further advances since then, creating some uncertainty as to what GDMT actually means today.”
New terminology now describes three therapy classes: foundational medical therapy (has the strongest evidence for unselected patients), additional medical therapy (evidence supports improved symptoms/quality of life or improved outcomes in specific subsets of patients) and guideline-directed interventional therapy (includes recommended implantable devices or interventional therapies). “These terms are designed to be dynamic and to remain contemporary over time as new drugs and devices are approved,” noted Professor Køber.
Important changes to recommendations for specific therapies have been made based on new evidence. These include Class I recommendations for mineralocorticoid receptor antagonists in chronic heart failure independent of LVEF and Class IIa recommendations for semaglutide or tirzepatide in patients with preserved LVEF and obesity. There are also upgraded recommendations for other treatments in specific situations, such as digoxin/digitoxin in chronic heart failure, durable mechanical circulatory support and transcatheter edge-to-edge repair of the mitral valve.
The document includes a section on patient education and self-care. “Education and lifestyle advice empower patients to manage their heart failure and engage in shared decision-making. A version of the 2026 guidelines for patients3 is now available, which helps to equip patients to be partners in their own care,” concluded Associate Professor Adamo.
Reference:
Lars Køber, Marianna Adamo, Anne-Christine Ruwald, Daniela Tomasoni, Lisa J Anderson, Charlotte Andersson, Jasper J Brugts, Ovidiu Chioncel, Erwan Donal, Peter Ferdinandy, Pardeep S Jhund, Francisco Leyva, Roberto Lorusso, Michael Madigan, Wilfried Mullens, Stefania Paolillo, Nicola Ryan, Maggie Simpson, Holger Thiele, Jens Jakob Thune, Emeline M Van Craenenbroeck, Linda W Van Laake, Mariette Verbakel, ESC Guidelines Advisory Group , 2026 ESC Guidelines for the management of heart failure: Developed by the task force for the management of heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS), European Heart Journal, 2026;, ehag100, https://doi.org/10.1093/eurheartj/ehag100
