New ESC heart failure guidelines include major updates
New European Society of Cardiology (ESC) heart failure guidelines represent a complete overhaul compared to its previous recommendations. The new document was published in European Heart Journal and will be presented at ESC Congress 2026.[1]
The foundational changes to the guidelines include moving to a new level of evidence system similar to that used in the U.S. It also changes the descriptions and classifications for various heart failure stages.
This guideline updates and replaces the previous version from 2021. It emphasizes that heart failure is not a single disease, but a clinical syndrome comprising various symptoms that are caused by the heart not functioning properly. The ESC also stressed that more needs to be done to better diagnose and manage these patients.
Prevention of heart failure is key to reduce high mortality rates
The prevalence of heart failure is estimated to be 1–3% in the general adult population. While mortality rates have improved considerably over the past 30 years, ESC said less than 60% of patients diagnosed with heart failure are still alive five years later.
“The overall burden of heart failure is expected to rise due to an aging population and greater prevalence of risk factors and obesity,” Professor Lars Køber, guideline task force chair and a clinician with Rigshospitalet - Copenhagen University Hospital in Denmark, said in a statement. “One of the key points we have tried to emphasize in the 2026 guidelines is the importance of prevention and starting treatment as early as possible.”
Changes in heart failure staging
Several changes were made to how heart failure is defined. This includes changes in language to better reflect what specialists now understand about heart failure.
Køber said the 2026 guidelines include a new 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). Also, heart failure was previously described as either "chronic" or "acute," but these have been updated so "acute" is now replaced by the term "decompensated."
“This change was made for clarity,” Marianna Adamo, another task force chair and an associate professor from University and Civil Hospital of Brescia, Italy, said in the same statement. “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.”
Previously, the ESC divided heart failure into three phenotypes based on left ventricular ejection fraction (LVEF). The new guidelines removed the classification of "heart failure with mildly reduced ejection fraction" (LVEF of 41-49%), and now describe two phenotypes. These are "heart failure with reduced ejection fraction," defined as an LVEF of less than 50%, and "heart failure with preserved ejection fraction," defined as an LVEF of 50% or more.
“The mildly reduced LVEF phenotype was introduced in previous guidelines to focus on patients not usually included in clinical trials," Adamo said. "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.”
New terminology describes three therapy classes
The new document also introduces new nomenclature to describe different types of heart failure therapies.
“The term ‘guideline-directed medical therapy (GDMT)’ was introduced more than 10 years ago,” Køber said. “However, there have been further advances since then, creating some uncertainty as to what GDMT actually means today ... These new terms are designed to be dynamic and to remain contemporary over time as new drugs and devices are approved."
The first class, "foundational medical therapy" has the strongest evidence for unselected patients. The next class, "additional medical therapy" has evidence supporting improved symptoms and quality of life, or improved outcomes in specific subsets of patients. The last class, "guideline-directed interventional therapy," includes recommended implantable devices or interventional therapies.
Additional changes in the new ESC guidelines
The guidelines also include a new system for grading levels of evidence. It closely resembles those used in U.S. guidelines. For therapy and prevention, the new grading system considers the study type and the number of studies supporting a recommendation. A separate grading system was also developed for diagnostic tests and prediction models.
Important changes in therapy recommendations were also included in this document. One big update is the Class I recommendation for mineralocorticoid receptor antagonists in chronic heart failure independent of LVEF and the Class IIa recommendations for semaglutide and 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 (M-TEER).
On top of these updates, the new guidelines also include a separate section on patient education and self-care. Adamo said education and lifestyle advice often empower patients to manage their heart failure and to better engage in shared decision-making. On a related note, a patient version of the 2026 guidelines is now available to help patients to be better partners in their own care.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]