ESC Congress 2026: Earlier treatment, simpler classification—new ESC guideline updates heart failure care

Clinical takeaway: For symptomatic heart failure, think earlier, simpler, and broader. The new ESC guideline recommends SGLT2 inhibitors and mineralocorticoid receptor antagonists as foundational therapy across the full range of ejection fractions, while emphasizing rapid initiation and optimization of treatment before and after hospitalization.

The 2026 ESC heart failure guideline, presented at ESC Congress 2026 and published simultaneously in the European Heart Journal, introduces some of the most significant changes in years, reflecting growing evidence that many heart failure therapies work across a broader spectrum of left ventricular function than previously recognized. The document also places greater emphasis on prevention, early intervention, and treatment optimization.

“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,” said guideline co-chair Lars Køber.

Perhaps the biggest conceptual change is the elimination of heart failure with mildly reduced ejection fraction (HFmrEF). The guideline now recognizes just 2 phenotypes: heart failure with reduced ejection fraction (HFrEF), defined as LVEF <50%, and heart failure with preserved ejection fraction (HFpEF), defined as LVEF ≥50%. Authors say patients in the former HFmrEF category resemble HFrEF patients biologically and therapeutically, making the previous three-part classification unnecessarily complex.

The guideline also adopts a staging framework that spans patients at risk for heart failure (stage A) through advanced heart failure (stage D), mirroring a growing focus on prevention and earlier disease recognition. In addition, the term “acute heart failure” has largely been replaced with “decompensated heart failure,” which guideline authors believe more accurately reflects the clinical course of many patients.

Drug therapy recommendations were also reorganized. The guideline introduces “foundational medical therapy,” referring to treatments with the strongest evidence for reducing hospitalization and death. For HFrEF, foundational therapy now consists of a beta-blocker, ACE inhibitor/ARNI/ARB, mineralocorticoid receptor antagonist (MRA), and SGLT2 inhibitor. For HFpEF, SGLT2 inhibitors and MRAs are considered foundational therapies.

Among the most notable recommendation updates is a Class I recommendation for MRAs in symptomatic heart failure regardless of LVEF. SGLT2 inhibitors also receive a Class I recommendation across the full heart failure spectrum.

The guideline further expands the role of obesity pharmacotherapy in HFpEF. Semaglutide or tirzepatide receive a Class IIa recommendation for patients with symptomatic heart failure, preserved LVEF, and obesity to improve weight, exercise capacity, and quality of life, regardless of diabetes status.

Several established therapies were upgraded. Digoxin or digitoxin moved to a Class IIa recommendation for selected patients with symptomatic HFrEF despite optimal foundational therapy, while recommendations were also strengthened for durable mechanical circulatory support and transcatheter edge-to-edge mitral valve repair in appropriate patients.

The guideline strongly emphasizes rapid uptitration and maintenance of foundational therapy, recommending dose escalation every 1 to 2 weeks when feasible and continued treatment even when patients become asymptomatic or experience marked improvement in ejection fraction.

What's changed at a glance

• HFmrEF has been eliminated; HFrEF is now defined as LVEF <50% and HFpEF as LVEF ≥50%.
• “Acute heart failure” has been replaced by “decompensated heart failure.”
• Heart failure stages A through D have been formally adopted, emphasizing prevention and earlier intervention.
• New treatment terminology introduced: foundational medical therapy, additional medical therapy, and guideline-directed interventional therapy.
• Class I recommendation for MRAs in symptomatic heart failure regardless of LVEF.
• SGLT2 inhibitors remain Class I therapy across the heart failure spectrum.
• Semaglutide and tirzepatide gain Class IIa recommendations for obese patients with HFpEF.
• Digoxin/digitoxin recommendation upgraded to Class IIa in selected HFrEF patients.
• Greater emphasis on rapid optimization of foundational therapy during and after heart failure hospitalization.

Source: Køber L, et al. (2026 Aug 28) Eur Heart J. 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)