European Heart Journal2026 ESC Guidelines for the Management of Heart Failure

✅ Guideline Update

The 2026 ESC guideline introduces a revised heart failure taxonomy, defining HFrEF as symptomatic heart failure with LVEF below 50% and HFpEF as symptomatic disease with LVEF of at least 50% plus objective cardiac abnormalities. It adopts stages A through D and replaces “acute heart failure” with “decompensated heart failure.” The guideline also formalizes foundational medical therapy across phenotypes, emphasizing treatment initiation, rapid titration, continuation after ejection-fraction improvement, and structured management before and after hospitalization.

Clinical Considerations

• HFrEF foundational therapy comprises an ARNI or ACE inhibitor, an ARB when needed, a beta-blocker, an MRA, and an SGLT2 inhibitor.
• HFpEF foundational therapy now includes MRAs and SGLT2 inhibitors, reflecting the guideline’s expanded evidence-based pharmacologic approach to preserved-ejection-fraction disease.
• Foundational medical therapy should be titrated at least every one to two weeks, guided by symptoms, vital signs, laboratory findings, and tolerability.
• Treatment should generally continue at the highest tolerated doses when patients become asymptomatic or experience LVEF improvement, because improvement does not necessarily indicate resolution of disease risk.
• In stabilized patients hospitalized with decompensated heart failure, in-hospital SGLT2 inhibitor initiation is recommended to improve quality of life and congestion symptoms and reduce heart failure hospitalization risk.
• The guideline emphasizes natriuretic peptides, echocardiography, and multimodality etiologic assessment, alongside screening for diabetes, kidney disease, obesity, iron deficiency, frailty, anxiety, and depression.

Practice Applications

• Recognize the revised LVEF boundary when classifying HFrEF and require objective structural or functional evidence when diagnosing HFpEF.
• Review eligible patients for complete foundational therapy rather than relying on a sequential, single-agent treatment approach.
• Monitor and titrate therapy through frequent assessment of symptoms, blood pressure, renal function, electrolytes, and medication tolerance.
• Integrate treatment optimization into hospitalization and early follow-up, including SGLT2 inhibitor initiation after stabilization when clinically appropriate.
• Avoid routine withdrawal of foundational therapy solely because symptoms resolve or LVEF improves; discontinuation is reserved for highly selected, closely monitored circumstances.