New ESC heart failure guidelines simplify classification and introduce ‘foundational’ therapy

New 2026 ESC Guidelines for the management of heart failure introduce major changes to the classification of heart failure and its treatment.

The European Society of Cardiology (ESC) has published new guidelines for the management of heart failure (HF), presented today at ESC Congress 2026 in Munich. The guidelines replace the 2021 recommendations and introduce new classifications for HF stages, phenotypes and therapies.¹

A major change is the adoption of four HF stages, ranging from patients at risk of developing HF (stage A) through to advanced HF (stage D), reflecting an increased emphasis on prevention and earlier identification of disease. The guidelines also simplify classification according to left ventricular ejection fraction (LVEF): HF with mildly reduced ejection fraction has been removed, with HF with reduced ejection fraction (HFrEF) now defined as LVEF below 50% and HF with preserved ejection fraction (HFpEF) as LVEF of 50% or above. The term ‘decompensated HF’ also replaces ‘acute HF’.¹

Don’t miss out on hearing about our latest peer-reviewed articles, expert opinions, conference news, podcasts and more.

Register Register

From GDMT to foundational therapy

Another notable change is new terminology intended to provide greater clarity around the role of different HF treatments.

The guidelines introduce foundational medical therapy (FMT) for treatments with a Class I recommendation for the general HF population and convincing evidence of reducing morbidity and/or mortality. Additional medical therapy (AMT) encompasses other recommended medical therapies, including those used in specific patient groups or with evidence for improving symptoms or quality of life. Guideline-directed interventional therapy (GDIT) covers recommended cardiac devices and interventional therapies.¹

Speaking during the guideline presentation, Task Force Chair Professor Lars Køber explained that the increasing number of recommended HF therapies had made the meaning of guideline-directed medical therapy (GDMT) less clear. A treatment receiving a guideline recommendation, he noted, did not necessarily mean it should form part of the core treatment given to the general HF population.

The new FMT classification is intended to distinguish these foundational treatments. Professor Køber also emphasized that the terminology is designed to be dynamic, allowing therapies to move from additional to foundational treatment as new evidence emerges.

In the 2026 guidelines, FMT comprises beta-blockers, ACE inhibitors/angiotensin receptor–neprilysin inhibitors/angiotensin receptor blockers, mineralocorticoid receptor antagonists (MRAs) and sodium–glucose cotransporter-2 (SGLT2) inhibitors for HFrEF, and MRAs and SGLT2 inhibitors for HFpEF.¹

Importantly, the guidelines retain GDMT as an overarching term: guideline-directed medical therapy includes both FMT and AMT.¹

Among the therapeutic updates, MRAs now have a Class I recommendation for chronic HF independent of LVEF. Semaglutide or tirzepatide receive Class IIa recommendations in patients with HFpEF and obesity, while recommendations have also been updated for treatments including cardiac glycosides, durable mechanical circulatory support and mitral transcatheter edge-to-edge repair.^1,2

Earlier referral for advanced heart failure

The guidelines also place greater emphasis on recognizing advanced HF, now classified as stage D, and identifying patients who may require specialist assessment.

During the presentation, Task Force Chair Associate Professor Marianna Adamo explained that the advanced HF section emphasizes earlier referral of patients with advanced HF, or those at risk of progressing to advanced HF, to a specialist center. She also highlighted efforts to simplify the referral algorithm and provide clinicians with easier criteria for identifying these patients.

This is reflected in the published guideline, which gives a Class I recommendation for early consultation with an advanced HF center in patients with advanced HF, or those at risk of advanced HF, who may be candidates for heart transplantation or durable mechanical circulatory support.¹

The guidelines also describe the ‘Rule of three’ and ‘I NEED HELP’ criteria as tools for identifying patients at high risk of advanced HF and supporting timely referral.¹

Overall, the 2026 guidelines represent a substantial restructuring of the approach to HF, combining updated treatment recommendations with simpler disease classifications and a greater emphasis on prevention, early treatment and recognition of advanced disease.

References

1. Køber L, Adamo M, Ruwald A-C, et al. 2026 ESC Guidelines for the management of heart failure. European Heart Journal. 2026. doi:10.1093/eurheartj/ehag100.
2. European Society of Cardiology. Major changes made to the ESC Guidelines on heart failure. August 28, 2026.