The 2026 ESC Guidelines for the Management of Heart Failure (HF), unveiled at ESC 2026, introduce major changes to HF classification and staging, along with new therapeutic nomenclature.
HF has been redefined. The mildly reduced ejection fraction category (HFmrEF) has been scrapped, leaving HF with only two distinct phenotypes:
“We have been primarily focused on classification based on ejection fraction,” said Dr Lars Køber, task force chair for the ESC guidelines and of the Rigshospitalet and Herlev-Gentofte Hospital, Copenhagen, Denmark. “There were three classes: reduced, mildly reduced, and preserved HF. But the middle category, mildly reduced, was problematic because no trial had ever been conducted in that group for any treatment. It has always been grouped with either the lower or the higher ejection fraction.”
Dr Lars Køber
However, from a pathophysiological perspective, “we know that these patients seemed to belong to and benefit from the same treatments as those with reduced ejection fraction,” he continued. “So we simplified and merged the two groups, as we think this is more realistic.”
The new guideline also replaces acute HF with decompensated HF. Køber said this update reflects the acute or gradual onset of signs and symptoms that require urgent medical intervention.
A-D staging
To highlight early detection, prevention, and prompt intervention, the guideline adopts an A-D staging system aligned with the 2022 US HF guidelines.
Core therapies
The guideline introduces new classifications for HF therapies. The guideline now classifies options into foundational medical therapy (FMT), additional medical therapy (AMT), and guideline-directed interventional therapy (GDIT). These terms are intended to be dynamic and may therefore remain current as new drugs and devices are approved. [Eur Heart J 2026;doi.org/10.1093/eurheartj/ehag100]
“One of the biggest problems in HF is the underuse of drugs, which means you either don’t give them or give them at a dosage that’s too low,” said Køber. “So we tried to create a system in which you have something that, in principle, everyone should have, and that is what we defined as FMT.”
FMT includes medical therapies for unselected patients with HF, with a Class 1 recommendation to reduce HF hospitalization and mortality. It encompasses quadruple therapy with a beta-blocker, a renin-angiotensin-aldosterone system (RAAS) inhibitor, a mineralocorticoid receptor antagonist (MRA), and a sodium-glucose cotransporter 2 (SGLT2) inhibitor for patients with HF with reduced ejection fraction (HFrEF). For HF with preserved ejection fraction (HFpEF), FMT comprises an MRA and an SGLT2 inhibitor.
In brief, MRAs and SGLT2 inhibitors are advised for all symptomatic patients with HF, regardless of left ventricular ejection fraction (LVEF). Other agents can be used in selected cases.
AMT includes other medications with class IIa/IIb recommendations, or class I recommendations for improving symptoms and quality of life, or reducing morbidity and mortality in specific subsets of patients with HF. The GDIT category, meanwhile, includes all guideline-recommended implantable devices or other interventional therapies.
Patients with advanced HF refractory to FMT and GDIT, without absolute contraindications, should be referred promptly for consideration of heart transplantation or mechanical circulatory support.
The guideline was developed with the special contribution of the ESC’s Heart Failure Association and endorsed by the European Association for Cardio-Thoracic Surgery.