The 2026 ESC Guidelines for the management of heart failure introduce new concepts for the classification, diagnosis, and treatment of heart failure. They also incorporate recommendations for decompensated heart failure, advanced heart failure, and the management of various comorbidities.
The new guidelines also place greater emphasis on prevention, early intervention, and a multidisciplinary approach. Therefore, understanding these changes can help provide insight into how the management of patients with heart failure is evolving.
Below is a summary of the key recommendations highlighted in the Official Slide Set accompanying this document.
By América Torres
What changes in the 2026 ESC Heart Failure Guidelines?
One of the most important changes relates to the classification of heart failure according to left ventricular ejection fraction (LVEF). The new guidelines:
- Expand the definition of HFrEF to include patients with an LVEF of up to 50%.
- Eliminate the HFmrEF category.
- Define HFpEF as LVEF ≥50%.
- Replace the term acute heart failure with decompensated heart failure.
- Introduce Stages A–D, ranging from patients with risk factors to those with advanced heart failure.
- Introduce new classifications for pharmacological and interventional therapies.
These changes modify how the disease is conceptualized and help establish an approach that is more focused on patient risk and disease progression.
Prevention of heart failure: intervening earlier
The new recommendations reinforce the importance of acting before clinical manifestations of heart failure develop.
Lifestyle and risk factors
In patients with Stage A or B disease, counseling on healthy lifestyle habits is recommended. This includes maintaining an appropriate weight, following a balanced diet, and avoiding a sedentary lifestyle. Smoking cessation and avoiding excessive alcohol consumption are also recommended. In addition, the guidelines include recommendations to avoid drugs such as cocaine, amphetamines, and anabolic steroids.
New recommendations for patients with diabetes
In people with type 2 diabetes and at least one other cardiovascular risk factor, a GLP-1 receptor agonist should be considered to reduce the risk of heart failure or cardiovascular death. In patients with established cardiovascular disease or elevated cardiovascular risk, this approach reinforces the importance of treating factors that may contribute to progression toward heart failure.
Diagnosing heart failure: Greater attention to underlying causes
The 2026 ESC Heart Failure Guidelines include specific recommendations for identifying certain cardiomyopathy etiologies.
Evaluation for cardiac amyloidosis
When cardiac amyloidosis is suspected, an initial evaluation including serum and urine immunofixation, serum free light chains, and bone scintigraphy with DPD, PYP, or HMDP is recommended. This can help identify a specific cause of heart failure and cardiomyopathy.
Genetic testing in cardiomyopathies
These clinical practice guidelines (CPGs) also recommend genetic testing when it may contribute to diagnosis, prognosis, or treatment selection. In addition, genetic testing may be useful for cascade screening of family members who would otherwise require prolonged follow-up.
Heart failure treatment: Optimizing therapy early
One of the key messages of the new 2026 ESC recommendations for heart failure is the importance of systematically optimizing pharmacological treatment.
Treatment titration every 1–2 weeks
In patients with heart failure, pharmacological treatment should be progressively up-titrated, at least every one to two weeks. Adjustment should be based on symptoms, vital signs, and laboratory results. The goal is to reach the doses shown to be effective in clinical trials and reduce the risk of hospitalization or death.
Should treatment be discontinued when LVEF improves?
Not necessarily. The new CPGs recommend maintaining the maximum tolerated doses even in patients who are asymptomatic or have experienced an improvement in LVEF. Therefore, clinical or ventricular function improvement does not automatically mean that treatment should be withdrawn. In highly selected cases, gradual dose reduction or discontinuation may be considered. However, this requires frequent clinical, laboratory, and imaging follow-up.
Decompensated heart failure: New strategies during hospitalization
The management of decompensated heart failure also incorporates new recommendations.
In-hospital initiation of SGLT2 inhibitors
After initial stabilization, initiation of an SGLT2 inhibitor during hospitalization is recommended in patients with decompensated heart failure. The goal is to improve quality of life and symptoms related to congestion. In addition, it may reduce the risk of rehospitalization for heart failure.
Urine sodium-guided diuretic therapy
During the first days of treatment, a diuretic strategy guided by urinary sodium may be considered to improve natriuresis and diuresis. This adds a monitoring tool to the management of congestion in hospitalized patients.
Cardiogenic shock: More careful selection of circulatory support
The recommendations also provide a better distinction between patients who may benefit from temporary mechanical circulatory support. When this type of intervention is considered, involvement of a multidisciplinary shock team is recommended. Its role is to guide device selection and the mode of support according to the patient’s characteristics and heart failure status.
The guidelines also identify specific situations in which temporary mechanical support may be considered. In contrast, they do not recommend its indiscriminate use in unselected patients with cardiogenic shock secondary to acute myocardial infarction.
Advanced heart failure: Earlier referral
Timely identification of advanced disease becomes increasingly important.
Early consultation with specialized centers
The guidelines recommend early consultation with a specialized heart failure center for patients with advanced disease or those at risk of developing it. The goal is to timely assess the possibility of heart transplantation or long-term mechanical circulatory support when the patient is a candidate for these procedures. This approach may facilitate planning before clinical deterioration limits therapeutic options.
Obesity and comorbidities: A more comprehensive approach
The new 2026 ESC recommendations for heart failure also place particular emphasis on conditions that coexist with heart failure.
Semaglutide and tirzepatide in patients with obesity
In patients with symptomatic heart failure, LVEF ≥45%, and a BMI ≥30 kg/m², semaglutide or tirzepatide should be considered, regardless of the presence of diabetes. The goal is to reduce body weight and improve exercise capacity and quality of life. Bariatric surgery may also be considered in selected patients with heart failure and a BMI ≥35 kg/m² when structured lifestyle changes and weight-loss medications do not achieve sustained weight loss.
Assessing anxiety, depression, and frailty
The management of heart failure is not limited to the cardiovascular system. The 2026 ESC CPGs on heart failure recommend considering assessment of anxiety, depression, and frailty. This information can help healthcare professionals develop personalized care plans and identify factors associated with adverse outcomes.
Exercise and cardiac rehabilitation: An essential part of treatment
The new recommendations reinforce the role of personalized exercise.
Exercise training for stable patients
Personalized exercise training within multidisciplinary cardiac rehabilitation programs is recommended for stable patients unless specific contraindications are present. The goal is to improve exercise capacity and quality of life. It may also reduce the risk of hospitalization for any cause. Continued personalized exercise training is also recommended long term outside formal rehabilitation programs, when appropriate for the patient.
A more comprehensive view of heart failure
The 2026 ESC Guidelines for the management of heart failure broaden the approach to the disease. Heart failure management is no longer limited to controlling symptoms or treating reduced ejection fraction. The recommendations incorporate prevention, etiologic diagnosis, early treatment optimization, management of congestion, obesity, and other comorbidities. They also emphasize rehabilitation, multidisciplinary care, and early referral of patients with advanced disease.
Overall, these changes point toward earlier, more personalized, and continuous management of heart failure. For healthcare professionals, understanding these recommendations is an important step toward understanding how the new 2026 ESC heart failure guidelines may influence the evaluation and follow-up of patients with heart failure.
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Reference
FAQ: 2026 ESC Guidelines for the Management of Heart Failure
What are the main changes in the 2026 ESC Guidelines for the management of heart failure?
The 2026 ESC Guidelines update the LVEF-based classification by expanding HFrEF to include LVEF up to 50% and defining HFpEF as LVEF ≥50%, and they remove the HFmrEF category. They also adopt heart failure stages A–D, replace the term acute heart failure with decompensated heart failure, and introduce new classifications for medical and interventional therapies.
How is heart failure classified by LVEF in the 2026 ESC Guidelines?
In the 2026 ESC Guidelines, LVEF phenotypes are simplified and redefined as:
- HFrEF: heart failure with LVEF up to 50% (including LVEF 50%).
-  HFpEF: heart failure with LVEF ≥50%.
- HFmrEF: removed as an independent phenotype.
What do heart failure stages A–D mean in the 2026 ESC Guidelines?
The 2026 ESC Guidelines adopt a staging system A–D describing a continuum from patients with risk factors to advanced heart failure, to strengthen prevention, early detection, and timely intervention. (In the Official Slide Set provided, adoption of stages A–D is confirmed, but the operational definitions of each stage are not detailed.
What do the 2026 ESC Guidelines recommend for heart failure treatment during hospitalization?
For decompensated heart failure, after initial stabilization the guidelines recommend in-hospital initiation of an SGLT2 inhibitor to improve quality of life and congestion symptoms and reduce the risk of heart-failure hospitalization. In addition, during the first days of treatment, a urinary sodium–guided diuretic strategy may be considered to optimize natriuresis and diuresis.
What do the 2026 ESC Guidelines recommend for patients with heart failure and obesity?
In patients with symptomatic heart failure, LVEF ≥45%, and BMI ≥30 kg/m², the guidelines state that semaglutide or tirzepatide should be considered, regardless of diabetes status, to reduce body weight and improve exercise capacity and quality of life.