On August 28, 2026, the European Society of Cardiology (ESC) published the new guidelines for the treatment of heart failure. They bring about a number of important changes regarding both classification and pharmacological and non-pharmacological treatment.

One of the most notable changes is the simplification of the classification based on left ventricular ejection fraction (LVEF). The separate category HFmrEF (heart failure with mildly reduced LVEF) has been deleted. Heart failure with an LVEF < 50% will henceforth be considered and treated as HFrEF (heart failure with reduced LVEF), while HFpEF continues to be defined unchanged as heart failure with an LVEF ≥ 50%. This change reflects the growing evidence that heart failure patients with an LVEF of 41-49% align more closely with HFrEF than with HFpEF in terms of pathophysiology, prognosis, and response to various treatments.

In addition, the classification of heart failure into 4 stages (A to D) is receiving greater emphasis. Stage A includes patients with cardiovascular risk factors without structural heart disease, stage B patients with structural heart abnormalities but without symptoms (but thus an increased risk of progression to symptomatic heart failure), while stages C and D encompass symptomatic and advanced heart failure, respectively. As a result, the prevention of heart failure, particularly in stages A and B, is given an even more prominent place. Prevention of developing heart failure is achieved through a healthy lifestyle and good control of blood pressure, cholesterol, and diabetes mellitus.

Therapeutic terminology is also changing. The term guideline-directed medical therapy (GDMT) is subdivided into three components :

• Foundational Medical Therapy (FMT) : the basic or fundamental treatment (Class I recommendations – always recommended).
• Additional Medical Therapy (AMT) : additional treatments according to the individual patient profile (Class II recommendations – to be considered).
• Guideline-Directed Interventional Therapy (GDIT) : device- and interventional treatment.

The basic principle is clear: start fundamental therapy (FMT) as soon as possible in every suitable patient, and subsequently add treatments according to phenotype, comorbidities, and clinical condition.

The most important changes for daily practice are:

• Expansion of HFrEF treatment to LVEF < 50% instead of the previous £ 40%. The former HFmrEF group is integrated into HFrEF. As a result, neurohormonal treatment (ACE inhibitors, sartans, ARNI, beta-blockers, MRA) acquires a broader indication.
• Mineralocorticoid receptor antagonists (MRAs) are given a more prominent role across the entire LVEF spectrum. The new guidelines place MRAs within foundational medical therapy for heart failure, independent of LVEF. However, the greatest prognostic benefit is seen at an LVEF < 50%.
• Digitalis is once again a more prominent part of the therapeutic arsenal for HFrEF as additional therapy. Based on more recent data, the recommendation for low-dose digoxin or digitoxin is being upgraded, particularly in selected patients with more severe HFrEF, lower blood pressure, a faster resting heart rate, and a persistent risk of worsening heart failure. Digitalis should not be discontinued abruptly.
• GLP-1-based therapy is finding a place in HFpEF and obesity. Semaglutide and tirzepatide can be considered in these patients, even without diabetes, with beneficial effects on weight, symptoms, quality of life, functional capacity, and a reduction in the number of heart failure events. In patients with obesity and/or diabetes without symptomatic heart failure (stage A or B), this medication can also reduce the risk of progression to symptomatic heart failure (stage C or D).
• The former terminology 'acute heart failure' is being replaced by the term 'decompensated heart failure', because cardiac decompensation does not always occur rapidly or acutely requiring hospitalization. Sometimes cardiac decompensation develops more slowly, and sometimes outpatient treatment is possible. The therapeutic goal is the most complete decongestion possible. In addition to loop diuretics, acetazolamide or a thiazide diuretic may be added for more efficient decongestion. At the same time, there is a strong emphasis on the early initiation and uptitration of the FMT and the faster introduction of an SGLT2 inhibitor during hospitalization. After discharge, intensive follow-up is recommended for the first six weeks.
• In HFimpEF (heart failure with improved ejection fraction) caution remains required when tapering therapy. In principle, foundational therapy is continued unchanged after recovery of the LV ejection fraction. Phased tapering of medication can only be considered in carefully selected, long-term stable patients with complete normalization of cardiac function, under close clinical, echocardiographic, and biochemical monitoring.
• For device therapy, the focus is also shifting towards earlier intervention. In HFrEF with a wide QRS complex of ³150 ms and left bundle branch block, CRT (cardiac resynchronization therapy) should be considered and planned sooner, because the chance of improvement in LVEF with drug therapy is much lower in this group.
• Finally, multidisciplinary heart failure care remains essential. Patient education, monitoring of adherence and volume status, rehabilitation, prevention of medication-related harm, and well-organized transmural follow-up remain crucial components of high-quality heart failure care.

The new ESC guidelines therefore entail not only an adjustment of individual treatment recommendations, but above all a further shift towards early prevention, rapid implementation of prognostically important therapies, and an individualized, multidisciplinary approach across the entire heart failure spectrum.

Modification of this website

Over the coming months, we will gradually adapt this website to the new ESC Heart Failure 2026 Guidelines. The information for healthcare providers is being updated according to the new classifications, terminologies, and therapeutic recommendations.

The patient section is also being thoroughly revised. In doing so, we aim not only to adapt the content to the new guidelines but also to formulate the information in an even more accessible and patient-friendly manner, so that patients and their relatives better understand what heart failure is, what treatments are available, and why proper follow-up is so important.