ESC 2026 Heart Failure — Clinical Reference

What changed, in one line: HFmrEF is gone, HF is now staged A→D, "acute HF" is now "decompensated HF (DHF)", and GDMT is split into three named tiers (FMT / AMT / GDIT).

Why the revision

Task Force rationale

Prevention-first framing: burden of HF rising with ageing population + obesity/risk-factor prevalence
Goal: start treatment as early as possible, not only after symptomatic HF develops
Task Force Chairs: Lars Køber (Copenhagen), Marianna Adamo (Brescia)

Presented ESC Congress 2026, Munich. Published online 28 Aug 2026, European Heart Journal.

Epidemiology & definition (unchanged basis)

Burden of disease

HF prevalence: 1–3% of the general adult population
<60% of patients diagnosed with HF are alive at 5 years despite improved mortality over 3 decades
HF is a clinical syndrome, not a single disease — signs/symptoms caused by the heart failing to function normally (structural and/or functional cardiac abnormality → reduced cardiac output and/or elevated intracardiac pressures at rest or on stress)

Structure of this reference

Diagnosis — symptoms/signs, natriuretic peptides, ECG, echo criteria for each phenotype
Phenotype/Stage — new 2-phenotype LVEF split + 4-stage (A–D) framework, incl. Stage A/B risk factors
Therapy Terms — retirement of "GDMT"; new FMT / AMT / GDIT tiers
Rx Upgrades — specific recommendation changes named in the release (MRA, incretins, digoxin/digitoxin, MCS, TEER), with monitoring
Gaps & PSU — what is NOT yet extractable from secondary sources, and local practice flags

Diagnostic biomarker/imaging cutoffs are unchanged in the 2026 update — the revision changed classification and terminology, not the core diagnostic algorithm below (carried over from 2021 ESC HF Guideline / 2023 HFA-NT-proBNP consensus).

Symptoms & signs

Typical symptoms

Breathlessness (exertional → orthopnea → paroxysmal nocturnal dyspnea)
Ankle swelling, fatigue, reduced exercise tolerance
Less specific: nocturnal cough, wheeze, bloating, weight gain >2 kg/wk (fluid), weight loss (advanced/cardiac cachexia), confusion (esp. elderly)

Signs

Elevated JVP, hepatojugular reflux, S3 gallop, laterally displaced apex beat
Pulmonary crackles, pleural effusion, peripheral/sacral edema, ascites, hepatomegaly
Tachycardia, tachypnea, cool peripheries in low-output states

Diagnostic workup — stepwise

1 · Suspected HF (symptoms/signs, or risk factors: HTN, CAD, DM, cardiotoxic exposure)

↓

2 · ECG + Natriuretic peptide (NT-proBNP/BNP)

↓ NP below cutoff + normal ECG → HF unlikely

3 · Echocardiography if NP elevated or ECG abnormal

↓

4 · Classify by LVEF (HFrEF vs HFpEF) + assign Stage (A–D)

Test	Rule-out threshold	Notes
NT-proBNP	<125 pg/mL (non-acute)	Age-adjusted rule-in: ≥125 (<50y), ≥250 (50–74y), ≥500 (≥75y) pg/mL per HFA consensus; lower thresholds in obesity
BNP	<35 pg/mL (non-acute)	Acute setting cutoffs are higher (BNP <100, NT-proBNP age-banded higher) — use acute HF cutoffs in ED/ward
MR-proANP	<40 pmol/L	Less commonly available
ECG	Completely normal ECG makes HF unlikely	Look for AF, Q waves, LVH, LBBB, low voltage

Reference: HFA of ESC clinical consensus on practical NT-proBNP algorithms (Eur J Heart Fail 2023); 2021 ESC HF Guideline diagnostic thresholds (Eur J Heart Fail 2022).

Echocardiographic criteria by phenotype

Phenotype	LVEF	Required supporting criteria
HFrEF (2026: absorbs old HFmrEF)	<50%	Symptoms/signs alone sufficient with LVEF <50%
HFpEF	≥50%	Symptoms/signs + elevated NP + ≥1 of: relevant structural disease (LVH, LA enlargement) or diastolic dysfunction on echo

Whether the 2026 guideline revises the HFpEF diagnostic algorithm (e.g. H2FPEF/HFA-PEFF scoring) itself is not confirmed from secondary sources — needs full-text verification.

Phenotype simplification

LVEF measured

↓

HFrEFLVEF <50% — now absorbs the old HFmrEF band (41–49%)

HFpEFLVEF ≥50% — unchanged definition

HFmrEF retired

Old 3-tier system (HFrEF / HFmrEF / HFpEF) replaced by this 2-tier system
Rationale (Adamo): HFmrEF patients share pathophysiology and treatment response with HFrEF — trial data support treating them the same way rather than as a distinct group

4-stage framework (adopted from US ACC/AHA model)

Stage A — At risk

↓ develops cardiac structural/functional abnormality

Stage B — Pre-HF

↓ signs/symptoms appear

Stage C — Symptomatic HF

↓ refractory despite optimal therapy

Stage D — Advanced HF

Stage	Definition
A	At risk for HF — no signs, symptoms, or cardiac structural/functional abnormality
B	Pre-HF — cardiac structural/functional abnormality present, but no current or prior signs/symptoms
C	Symptomatic HF — structural abnormality plus current or prior signs/symptoms
D	Advanced HF

Stage A — "at risk" criteria (standard risk factors carried into staging)

Hypertension, type 2 diabetes, obesity, metabolic syndrome
Exposure to cardiotoxic agents (anthracyclines, HER2-targeted therapy, radiotherapy to chest)
Family history of cardiomyopathy or genetic cardiomyopathy variant carrier, without phenotype
Atherosclerotic CVD risk factors without established CAD

Screening implication: NT-proBNP/BNP-based screening in at-risk populations to detect Stage B before symptoms develop is emphasized as part of the 2026 prevention focus.

Stage B — structural/functional markers (pre-HF)

LV systolic dysfunction (reduced LVEF) without symptoms
LV hypertrophy or diastolic dysfunction on imaging
Regional wall motion abnormality (e.g., prior silent MI)
Elevated natriuretic peptides or elevated cardiac troponin in the at-risk patient, without overt symptoms
Valvular heart disease of relevant severity, asymptomatic

"Acute HF" → "Decompensated HF (DHF)"

Terminology change

Replaces "acute HF" for clarity — many patients decline gradually rather than presenting with sudden-onset failure.

DHF = gradual or acute onset of symptoms/signs of HF severe enough to require urgent attention
Stated management principle: treat the trigger — diuretics for congestion, vasodilators for hypertensive presentations, etc.

DHF — clinical profiles (standard framework, terminology updated)

Congestion (wet)Most common (~90%). Elevated filling pressures — orthopnea, edema, elevated JVP. Mainstay: IV loop diuretic.

Hypoperfusion (cold)Low cardiac output — cool peripheries, confusion, worsening renal function. May need inotropes if SBP low.

Hypertensive DHFSBP often >140 with rapid-onset pulmonary congestion, preserved EF common. Mainstay: IV vasodilator (nitrate) + diuretic.

First-line DHF pharmacotherapy

Furosemide IV 20–40 mg bolus (2.5× home oral dose if already on diuretic) — reassess diuresis at 2h, double dose if inadequate
GTN infusion 10–20 mcg/min, titrate to SBP >90–100 — for congestion with adequate/high BP
Continue oral FMT (beta-blocker, ARNI/ACEi, MRA, SGLT2i) unless hemodynamically unstable — do NOT routinely withhold beta-blocker unless cardiogenic shock

This is standard DHF management per prior ESC acute HF guidance; the 2026 document's specific DHF algorithm/flowchart wording is not yet extractable from secondary sources.

GDMT retired as an umbrella term

Why

"GDMT" (coined 2013, AHA/ACC) had become ambiguous as more drug classes accumulated Class I/IIa evidence. Split into three explicit tiers so the framework stays current as new drugs/devices are approved.

All HF therapies

↓

FMTFoundational Medical Therapy — Class I, general HF population

AMTAdditional Medical Therapy — IIa/IIb, or Class I limited to symptoms/QoL or a subgroup

GDITGuideline-Directed Interventional Therapy — devices & interventional procedures, any recommendation class

Foundational Medical Therapy (FMT) — one drug per class, given simultaneously

Class I for the general HFrEF population. Pick ONE agent per class below — not all listed. "Optimal FMT" = highest guideline-tolerated dose of the chosen agent in each class.

1 · Beta-blocker

Drug (Brand)	Start	Target	Titration
★ Bisoprolol (Concor) — preferred	1.25 mg OD	10 mg OD	Double q2–4wk if tolerated
Carvedilol (Dilatrend)	3.125 mg BID	25 mg BID (50 BID if >85 kg)	Double q2wk
Metoprolol succinate ER (Betaloc ZOK)	12.5–25 mg OD	200 mg OD	Double q2wk

Bisoprolol preferred for OD dosing/compliance. Switch to carvedilol if concurrent uncontrolled hypertension (added alpha-blockade) or if the patient also needs afterload reduction.

2 · RAAS blockade

Drug (Brand)	Start	Target	Titration
★ Sacubitril–valsartan (Entresto) — preferred	24/26 mg BID (49/51 if ACEi/ARB-experienced)	97/103 mg BID	Double q2–4wk; wash out ACEi 36h before starting (angioedema risk)
Enalapril (ACEi)	2.5 mg BID	10–20 mg BID	Double q2–4wk

ARNI > ACEi on mortality/HF hospitalization (PARADIGM-HF). Use ACEi only if ARNI unavailable/unaffordable, or history of angioedema with ARNI (then ACEi is also contraindicated — use ARB instead).

3 · Mineralocorticoid receptor antagonist

Drug (Brand)	Start	Target	Titration
★ Spironolactone (Aldactone) — preferred	12.5–25 mg OD	50 mg OD	Check K⁺/Cr at 1wk, 4wk, then periodically; avoid if eGFR <30 or K⁺ ≥5.0
Eplerenone (Inspra)	25 mg OD	50 mg OD	Same K⁺/renal monitoring

Spironolactone preferred (cheapest, most HFrEF trial evidence — RALES). Switch to eplerenone if gynecomastia/breast tenderness or menstrual irregularity develop. Finerenone is NOT a substitute here — it's the HFpEF/HFmrEF-basis MRA, see Rx Upgrades tab.

4 · SGLT2 inhibitor

Drug (Brand)	Dose	Titration
Dapagliflozin (Forxiga)	10 mg OD (fixed)	None needed; hold during acute illness/fasting (sick-day rule)
Empagliflozin (Jardiance)	10 mg OD (fixed)	None needed; same sick-day rule

No preference between the two — equivalent trial evidence (DAPA-HF vs EMPEROR-Reduced) across the LVEF spectrum. Choose whichever is on formulary/cheaper.

These 4 classes are started together, each at low/no-titration dose, and up-titrated in parallel — not sequentially maxing one before starting the next (rapid parallel initiation, 2021/2023 ESC HF Guideline).

Additional Medical Therapy (AMT) — added on top of FMT for a specific indication

Class IIa/IIb, or Class I limited to symptoms/QoL or a subgroup. Not part of the simultaneous 4-pillar foundation — add only when the specific indication is present.

Ivabradine

5 mg BID → titrate to 7.5 mg BID (max); start at 2.5 mg BID if age >75 or bradycardia-prone

Indication: HFrEF, sinus rhythm, resting HR ≥70 bpm despite maximally tolerated beta-blocker (or beta-blocker intolerant)
Ineffective in AF — requires sinus rhythm

Hydralazine–isosorbide dinitrate

37.5/20 mg TID → titrate to 75/40 mg TID (max)

Indication: self-identified Black patients with HFrEF, NYHA III–IV despite FMT (A-HeFT); or as ACEi/ARB/ARNI substitute if renal-limited/hyperkalemic and MRA/RAAS blockade not tolerated

Vericiguat

2.5 mg OD → double q2wk → 10 mg OD (max)

Indication: HFrEF with a recent decompensation event (hospitalization or IV diuretic in outpatient) despite FMT — VICTORIA trial population
Check BP before each up-titration; avoid if SBP <100 mmHg

Digoxin / Digitoxin

Drug	Dose	Target level	Key caution
Digoxin (Lanoxin)	0.125–0.25 mg OD	0.5–0.9 ng/mL	Reduce to 0.0625–0.125 mg OD if eGFR <30, age >70, or low body weight
Digitoxin	0.05–0.1 mg OD	Not renally cleared	Preferred in advanced CKD; longer half-life

Indication: symptomatic HFrEF despite FMT (symptom/QoL benefit, no mortality benefit); or rate control in concurrent AF
Avoid loading without checking renal function/electrolytes; avoid with hypokalemia (arrhythmia risk)

Semaglutide / Tirzepatide

Drug (Brand)	Start	Titration	Max
Semaglutide SC (Wegovy)	0.25 mg weekly	Double q4wk: 0.5→1.0→1.7→2.4	2.4 mg weekly
Tirzepatide SC (Zepbound/Mounjaro)	2.5 mg weekly	+2.5 mg q4wk	15 mg weekly

Indication: HFpEF (LVEF ≥50%) with obesity (BMI ≥30) — 2026 Class IIa, see Rx Upgrades tab for trial data/cautions
Not indicated for HFrEF-based FMT — this is HFpEF/obesity-specific AMT

Guideline-Directed Interventional Therapy (GDIT)

All implantable electronic devices (e.g., ICD, CRT) and interventional therapies
Includes any level of recommendation, not just Class I

Named recommendation changes — with dosing

Mineralocorticoid receptor antagonists — Class I

Now independent of LVEF (previously HFrEF-only). Two options depending on phenotype/trial basis:

Drug	Start	Target	Notes
Spironolactone/eplerenone (steroidal)	12.5–25 mg OD	50 mg OD	HFrEF evidence base (RALES/EMPHASIS-HF); risk of gynecomastia (spironolactone)
Finerenone (non-steroidal, Kerendia) — HFmrEF/HFpEF basis	10 mg OD if eGFR ≤60; 20 mg OD if eGFR >60	20 mg OD (eGFR ≤60) or 40 mg OD (eGFR >60)	Titrate at 4wk if K⁺ and renal function permit (FINEARTS-HF, NEJM 2024;391:1475)

K⁺ >5.0 mmol/L or eGFR <25 mL/min/1.73m² — exclusion criteria used in finerenone trials; check K⁺/Cr 1–2wk after initiation/dose change.

Ongoing monitoring: K⁺ and eGFR at 1wk, 4wk post-titration, then every 3–6 months. Hold/reduce dose if K⁺ 5.0–5.5; stop if K⁺ >5.5 or eGFR falls >25% from baseline.

Semaglutide / Tirzepatide — Class IIa

HFpEF (LVEF ≥50%) with obesity (BMI ≥30 kg/m²).

Drug (Brand)	Start	Titration	Max
Semaglutide SC (Wegovy)	0.25 mg weekly	Double q4wk: 0.5→1.0→1.7→2.4 mg	2.4 mg weekly (STEP-HFpEF dose)
Tirzepatide SC (Zepbound/Mounjaro)	2.5 mg weekly	Increase 2.5 mg q4wk	15 mg weekly (SUMMIT trial MTD; some patients maintained at 5 or 10 mg per tolerability)

SUMMIT trial (Circulation 2025): tirzepatide reduced composite CV death/worsening HF by ~38% vs placebo in HFpEF+obesity; mean weight loss 15.7% vs 2.2% placebo.

Key cautions: GI side effects (nausea, vomiting) most common during up-titration — slow titration if not tolerated. Avoid rapid dose escalation. Caution/contraindicated in gastroparesis, personal/family history of medullary thyroid carcinoma or MEN2. Monitor for lean-mass loss with sustained weight loss in frail/older patients.

Digoxin / Digitoxin — upgraded recommendation

Drug	Dose	Target level	Key caution
Digoxin (Lanoxin)	0.125–0.25 mg OD	Serum level 0.5–0.9 ng/mL	Reduce to 0.0625–0.125 mg OD if eGFR <30 or age >70/low body weight
Digitoxin	0.05–0.1 mg OD	Not renally cleared — preferred in advanced CKD	Longer half-life; less dose adjustment needed for renal impairment

Do not load in acute settings without checking baseline renal function/electrolytes; avoid with hypokalemia (arrhythmia risk).

Durable mechanical circulatory support & TEER — device-level upgrades

Durable MCS (e.g., HeartMate 3 LVAD): upgraded recommendation for Stage D/advanced HF as bridge-to-transplant or destination therapy — no drug dosing applicable
TEER (e.g., MitraClip): upgraded recommendation for HF-associated functional mitral regurgitation — procedural, not pharmacologic

Class/Level-of-Evidence letters (e.g., "IIa-B") and the exact guideline recommendation wording are not reproduced in secondary press coverage — the primary EHJ text is paywalled at time of writing. Doses above are sourced from the pivotal trials underlying each recommendation (cited per drug), not copied from the ESC document itself.

Patient education/self-care

New dedicated section on education and lifestyle advice for shared decision-making
A patient-facing version of the 2026 guideline was released alongside the physician version