5 Things to Know About the 2026 ESC Heart Failure Guidelines

New heart failure (HF) guidelines from the European Society of Cardiology (ESC) eliminate a long-standing ejection fraction category, rename core therapy classes, and add a first-time recommendation for glucagon-like peptide-1 (GLP-1)-based therapy in patients with obesity and heart failure with preserved ejection fraction (HFpEF), replacing the society's 2021 guidance. The document was developed by the task force for the management of heart failure of the ESC with special contribution from the Heart Failure Association and endorsement from the European Association for Cardio-Thoracic Surgery, and every recommendation, new and revised, has been regraded under a newly published ESC evidence-grading system.¹ Here are 5 things the update tells clinicians and health plans.

1. HFmrEF Is Gone, and HFrEF Now Extends to LVEF 49%

The task force eliminated the heart failure with mildly reduced ejection fraction (HFmrEF) phenotype, reclassifying HF into 2 categories: Heart failure with reduced ejection fraction (HFrEF), defined as left ventricular ejection fraction (LVEF) below 50% with symptoms and/or signs of HF, and HFpEF, defined as LVEF of 50% or above with symptoms and objective evidence of diastolic dysfunction.¹ The change reflects evidence that patients previously labeled HFmrEF more closely resemble the HFrEF population in underlying pathophysiology and treatment response.

2. "Decompensated Heart Failure" Replaces "Acute Heart Failure"

The guidelines rename the acute HF category, with decompensated heart failure (DHF) now used to describe patients whose chronic HF has deteriorated, aligning terminology across the document's sections on hospitalization and shock management. The section also introduces a 3-phase framework for in-hospital management—initial management, stabilization, and predischarge/early postdischarge care—to standardize how clinicians sequence treatment decisions. New recommendations tied to this category include in-hospital initiation of sodium-glucose cotransporter 2 (SGLT2) inhibitors after stabilization to reduce congestion symptoms and hospitalization risk, along with urinary sodium-guided diuretic therapy in the first days of treatment to improve diuresis.

3. A New Therapy Taxonomy Replaces "GDMT" as the Umbrella Term

Guideline-directed medical therapy (GDMT) is split into foundational medical therapy (FMT)—β-blockers, ACE-I/ARNI/ARB, mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors for HFrEF, plus MRNAs and SGLT2 inhibitors for HFpEF—and additional medical therapy for agents with narrower or symptom-focused indications, such as ivabradine, vericiguat, and cardiac glycosides. A parallel category, guideline-directed interventional therapy, now covers devices and procedures such as cardiac resynchronization therapy and mitral transcatheter edge-to-edge repair.

4. Semaglutide or Tirzepatide Gets a Class IIa Recommendation for HFpEF With Obesity

For the first time, the ESC recommends that semaglutide or tirzepatide should be considered for patients with symptomatic HF, LVEF 45% or above, and BMI of 30 kg/m² or higher, regardless of diabetes status, to reduce body weight and improve exercise capacity and quality of life. The recommendation follows trial data showing tirzepatide reduced the risk of heart failure hospitalization or cardiovascular death by 38% and cut body weight by up to 21% in patients with obesity-related HFpEF, with regulatory filings for that indication anticipated.²

5. Prevention Thresholds Got Stricter, and 4-Stage Classification Is Formally Adopted

The guidelines lower the systolic blood pressure target to below 130 mm Hg for patients with hypertension or stage B HF, and they broaden SGLT2 inhibitor and GLP-1 receptor agonist use for HF prevention in patients with type 2 diabetes and cardiovascular risk factors.¹ The task force also formally adopted a 4-stage HF framework (A through D, ranging from at-risk to advanced disease), aligning more closely with the 2022 AHA/ACC/HFSA staging model and emphasizing earlier detection and risk-factor intervention.

Key Takeaway

The 2026 ESC guidelines mark a significant overhaul of HF classification and terminology in more than a decade, collapsing 3 ejection fraction phenotypes into 2, replacing the language used to describe guideline-directed therapy, and formally endorsing GLP-1-based obesity treatment for HFpEF for the first time.¹ Clinicians and patients may soon see these changes reshape how HF is diagnosed, staged, and treated across the full disease continuum, from patients at risk to those with advanced disease.

References

1. Køber L, Adamo M, Ruwald AC, et al. 2026 ESC Guidelines for the management of heart failure. Eur Heart J. Published online August 28, 2026. ehag100. doi:10.1093/eurheartj/ehag100
2. Campbell P. SUMMIT trial proves tirzepatide's benefit in HFpEF with obesity. HCPLive^®. November 16, 2024. Accessed September 8, 2026. https://www.hcplive.com/view/summit-trial-proves-tirzepatide-s-benefit-in-hfpef-with-obesity