2026 ESC Guidelines for Heart Failure Redefine Disease and Treatment Subtypes

The 2026 European Society of Cardiology (ESC) Guidelines on Heart Failure have been published, including new classifications for heart failure (HF) and more specific treatment definitions beyond guideline-directed medical therapy (GDMT).1

Presented at the ESC Congress 2026 in Munich, Germany, by Lars Køber, MD, professor of cardiology at Rigshospitalet – Copenhagen University Hospital and Task Force Chair, the present guidelines are centered around prevention, recategorizing HF into clearer subtypes to optimize intervention.1,2

“The overall burden of heart failure is expected to rise due to an ageing population and greater prevalence of risk factors and obesity,” Køber 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.”1

Among the key changes in the current document is the overhaul of HF phenotypes. In the past, HF was based on left ventricular ejection fraction (LVEF) – the present guidelines have now removed the classification of HF with mildly reduced ejection fraction (HFmrEF), defined as LVEF 41-49%. Instead, the document reestablishes the 2 main phenotypes of HF with preserved EF (HFpEF) and HF with reduced EF (HFrEF). The former includes all LVEF ≥50%, while the latter has been expanded to include LVEF <50%.2

Another key change is the introduction of new staging metrics for HF. Following adoption in the US, the ESC has similarly divided HF status into 4 separate risk categories. Stage A HF is defined as patients at risk for the disease but without signs, symptoms, and cardiac abnormalities. Stage B if pre-HF, defined as the presence of cardiac abnormalities without signs and symptoms. Stage C is symptomatic HF, with the presence of cardiac abnormalities and current or prior signs and/or symptoms, while Stage D is advanced HF.2

The authors also replaced the term “acute HF” with “decompensated” in the interest of clarity. Certain patients experience a gradual decline of heart function rather than the sudden onset of HF – decompensated HF (DHF) reflects this, as it refers to the gradual onset of symptoms and/or signs of HF severe enough to deserve urgent attention. Treatment of DHF centers on addressing associated triggers via diuretics for congestion, vasodilators for high blood pressure, and so on.1,2

Additionally, the new guidelines aim to redefine GDMT, first introduced in 2013 by the American Heart Association and the American College of Cardiology, to provide more clarity on what the term means. The authors subdivided GDMT into 2 constituent components, including foundational medical therapy (FMT) and additional medical therapy (AMT).1,2

“The term ‘guideline-directed medical therapy (GDMT)’ was introduced more than 10 years ago,” Køber said in a statement. “However, there have been further advances since then, creating some uncertainty as to what GDMT actually means today.”1

FMT refers broadly to all medical therapies with a Class I recommendation for the general HF population, including beta blockers, ACE/ARNIs, mineralocorticoid receptor agonists, and SGLT2 inhibitors. The guidelines also suggest that the term “optimal FMT” be used to refer to the highest tolerated doses according to the guidelines.2

AMT is defined as all other medical therapies with Class IIa/IIb recommendations, or those with a Class I recommendation with proven effect only on symptoms and/or quality of life (QoL), or those with a Class I recommendation in specific subsets of patients or HF phenotypes. Additionally, the document introduces guideline-directed interventional therapy (GDIT), including all implantable electronic devices and interventional therapies with any level of recommendation in the guidelines.2

References

1. European Society of Cardiology. Major changes made to the ESC Guidelines on heart failure. August 28, 2026. Accessed August 28, 2026. https://www.escardio.org/news/press/press-releases/major-changes-made-to-the-esc-guidelines-on-heart-failure/

2. Køber L, Adamo M, Ruwald A, et al. 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