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2026 ESC Heart Failure Guidelines: Practical Changes for Clinicians

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The 2026 European Society of Cardiology (ESC) guideline is a substantial update to heart-failure practice. It replaces the 2021 guideline and its 2023 focused update as the current ESC reference. Its main clinical message is to treat heart failure across a continuum: reduce risk early, recognise structural disease before symptoms where possible, and apply evidence-based treatment promptly once heart failure is established.1 2

The most visible changes are a simplified ejection-fraction classification, a stage-based framework, revised terminology for therapy, and new recommendations on mineralocorticoid-receptor antagonists (MRAs) and obesity treatment. These changes should improve clarity, but they do not replace careful phenotyping, aetiological investigation, or local prescribing and device pathways.

What has changed?

1. The LVEF classification has been simplified

The ESC now uses two heart-failure phenotypes based on left-ventricular ejection fraction (LVEF): heart failure with reduced ejection fraction (HFrEF) for LVEF <50%, and heart failure with preserved ejection fraction (HFpEF) for LVEF ≥50%. The previous separate category of heart failure with mildly reduced ejection fraction (HFmrEF; LVEF 41–49%) has been removed.1 3

This reflects the view that patients with LVEF in the 41–49% range often have a similar biology and treatment response to those with lower LVEF. It should not lead to treatment decisions being made from a single LVEF value. Image quality, loading conditions, rhythm, method of measurement and biological variation all matter. A patient with an LVEF close to 50% still needs an integrated assessment of symptoms, congestion, natriuretic peptides, structural heart disease, co-morbidity and cause.

The guideline also replaces the broad label acute heart failure with decompensated heart failure. This better captures patients whose deterioration is progressive rather than abrupt.3

2. Heart failure is framed as a staged condition

The new framework places greater emphasis on prevention and earlier intervention. It follows the progression from people at risk of heart failure (stage A), through pre-heart failure with structural or functional abnormalities but no symptoms (stage B), to symptomatic heart failure (stage C) and advanced heart failure (stage D).1 3

For day-to-day practice, this reinforces three points. First, hypertension, diabetes, obesity, chronic kidney disease, coronary disease and cardiotoxic exposure should be addressed before symptomatic heart failure develops. Second, asymptomatic left-ventricular dysfunction or structural heart disease warrants active follow-up rather than passive labelling. Third, advanced-heart-failure referral should not be delayed until every conventional option has been exhausted.

3. The guideline uses clearer treatment language

The ESC separates therapy into three groups.1 2

Term Meaning in the guideline Practical implication
Foundational medical therapy (FMT) Medical therapies with the strongest evidence for an unselected heart-failure population. Establish and optimise these first, unless contraindicated or not tolerated.
Additional medical therapy (AMT) Therapies with benefit in defined clinical settings or for selected outcomes. Add according to phenotype, rhythm, symptoms, co-morbidity and residual risk.
Guideline-directed interventional therapy (GDIT) Recommended device or structural interventions. Consider after appropriate medical optimisation and multidisciplinary assessment.

For symptomatic HFrEF, the familiar disease-modifying foundation remains a beta-blocker, renin–angiotensin system inhibition with an angiotensin-converting-enzyme inhibitor or an angiotensin-receptor neprilysin inhibitor, an MRA, and an SGLT2 inhibitor, tailored to clinical status and tolerance. The guideline recommends reviewing and uptitrating foundational treatment at least every one to two weeks, guided by symptoms, observations and laboratory results.1

Treatment updates most likely to affect practice

MRA treatment now spans the LVEF spectrum

A major change is the Class I recommendation for an MRA in chronic heart failure irrespective of LVEF.3 This is an important move beyond the previous evidence boundary between reduced and preserved ejection fraction.

The recommendation is supported by the established mortality and hospitalisation benefit of steroidal MRAs in HFrEF, together with newer evidence in patients with LVEF ≥40%. In FINEARTS-HF, finerenone reduced the rate of the composite of total worsening heart-failure events and cardiovascular death. The observed benefit was driven mainly by fewer worsening heart-failure events; cardiovascular death alone was not clearly reduced. Hyperkalaemia was more frequent.4

This does not mean that MRAs are interchangeable or suitable for every patient. Choice of agent, renal function and potassium thresholds, monitoring, interaction checks, local formulary rules and the product licence remain essential. In particular, this recommendation should not be used to bypass the need for repeat renal-function and potassium testing after initiation or dose change.

Obesity is treated as a therapeutic target in selected HFpEF-spectrum patients

The guideline gives a Class IIa, Level B recommendation that semaglutide or tirzepatide should be considered for patients with symptomatic heart failure, LVEF ≥45% and body-mass index ≥30 kg/m², regardless of diabetes status, to reduce weight and improve exercise capacity and quality of life.1

This recommendation is deliberately selective. In STEP-HFpEF, semaglutide improved symptoms, physical limitations, 6-minute walk distance and weight loss over 52 weeks in patients with HFpEF and obesity.5 In SUMMIT, tirzepatide reduced the composite of cardiovascular death or worsening heart failure and improved health status in patients with HFpEF and obesity; the trial was not powered to establish a reduction in cardiovascular death alone.6

For practice, these agents should be considered in addition to, not instead of, foundational heart-failure care, congestion management, rehabilitation and structured lifestyle support. Patient selection still requires attention to frailty, nutritional risk, gastrointestinal adverse effects, renal function, diabetes treatment and local eligibility or commissioning arrangements.

Selected therapies have a clearer place after foundational treatment

The guideline retains a selective role for cardiac glycosides. Digoxin or digitoxin should be considered in patients with symptomatic HFrEF, LVEF ≤40%, despite optimal foundational treatment, to reduce heart-failure hospitalisation.1 This is not a return to routine digoxin prescribing: there remains no established mortality benefit, and renal function, potassium, dose, interactions and toxicity risk must guide use. See our related review: Digoxin in Contemporary Heart-Failure Practice.

For selected patients with stable symptomatic HFrEF and severe secondary mitral regurgitation despite optimised foundational therapy and cardiac resynchronisation therapy where indicated, mitral transcatheter edge-to-edge repair is recommended when defined clinical and echocardiographic criteria are met.1 This remains a Heart Team decision, not an alternative to medical optimisation.

What should change in a practical heart-failure review?

A useful review now starts by recording the current phenotype as HFrEF (<50%) or HFpEF (≥50%), while documenting the actual LVEF and its context. Avoid carrying the historical HFmrEF label forward as if it were a current ESC category.

For a patient with symptomatic chronic heart failure, establish whether foundational treatment is complete and tolerated before moving to additional therapies. In HFrEF, this includes early sequencing and regular review rather than prolonged, single-drug titration. For all phenotypes, assess congestion, blood pressure, renal function, potassium, rhythm, iron status, diabetes, kidney disease, obesity, frailty and adherence.

For a patient with LVEF ≥45% and obesity, assess whether semaglutide or tirzepatide fits the individual’s phenotype and goals. The strongest guideline-supported outcomes are weight loss, exercise capacity and quality of life; treatment should not be presented as a universal heart-failure mortality therapy.

For every patient, reinforce self-management, medication review, exercise-based cardiac rehabilitation where appropriate, multidisciplinary follow-up and an early plan for deterioration. The guideline gives these elements a central—not optional—place in care.1

Pitfalls and limitations

The new LVEF threshold does not eliminate measurement uncertainty. A value near 50% should prompt clinical interpretation, not automatic reclassification without context.

An ESC Class I recommendation for MRAs does not remove safety constraints. Hyperkalaemia, worsening renal function, hypotension and interacting medication remain common barriers and require proactive monitoring.

The obesity recommendation applies to a defined symptomatic population with LVEF ≥45% and BMI ≥30 kg/m². It should not be extrapolated automatically to HFrEF below this range, to patients without obesity, or to those who cannot safely tolerate weight-reducing treatment.

ESC guidance informs practice in the UK, but it is not a substitute for NICE guidance, a medicine’s UK licence, local formulary approval or a specialist heart-failure pathway. Where these differ, clinicians should follow local governance while considering the evidence and the patient’s circumstances.

Key learning points

  • The 2026 ESC guideline replaces the separate HFmrEF category with HFrEF <50% and HFpEF ≥50%.
  • Heart failure is now framed as a staged condition, strengthening prevention, earlier recognition and timely referral.
  • The guideline uses the terms foundational medical therapy, additional medical therapy and guideline-directed interventional therapy to clarify treatment priorities.
  • MRAs now have a Class I recommendation in chronic heart failure across the LVEF spectrum, but agent choice and renal/potassium surveillance remain individualised.
  • Semaglutide or tirzepatide should be considered only for selected patients with symptomatic HF, LVEF ≥45% and BMI ≥30 kg/m²; the recommended aims are weight loss, exercise capacity and quality of life.
  • Digoxin remains a selected, safety-sensitive additional therapy rather than foundational treatment.

Educational note: This article summarises guideline changes for clinicians. It is not a prescribing protocol. Treatment decisions should incorporate the current medicine licence, local pathway, renal function, potassium, haemodynamics, co-morbidity and patient preference.

Publication date: 19 September 2026
Last reviewed: 19 September 2026

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