The European Society of Cardiology has published a full rewrite of its heart failure guidelines, changing how the condition is categorized and which drugs count as core treatment. The document was released online in the European Heart Journal and presented at ESC Congress 2026 in Munich, replacing recommendations that had stood since 2021.
Classification is not an academic exercise for people living with heart failure. The category a patient falls into determines which medicines a cardiologist is expected to offer, which referrals get triggered and, in many systems, what insurers cover. A boundary that moves a few percentage points can change a prescription.
The society estimates heart failure affects 1 to 3 percent of adults, and its announcement describing the major changes to the guidelines notes that fewer than 60 percent of those diagnosed are alive five years later.
Two Categories Replace Three in the New Ejection Fraction Model
The most consequential change simplifies how doctors sort patients by left ventricular ejection fraction, the share of blood the heart's main chamber pushes out per beat.
Heart failure with mildly reduced ejection fraction, previously defined as 41 to 49 percent, has been removed. Reduced ejection fraction now means below 50 percent. Preserved ejection fraction means 50 percent or above. The guidelines also retire the term acute heart failure in favor of decompensated heart failure.
Task Force Chair Marianna Adamo, an associate professor at the University and Civil Hospital of Brescia, said the mildly reduced group was created to focus attention on patients usually left out of clinical trials, but that these patients "share similar pathophysiology and benefit from similar treatments" as those with reduced ejection fraction. The name change from acute to decompensated was made for clarity, she said, because heart function often declines gradually rather than suddenly.
The document also adopts four disease stages running from patients merely at risk through advanced disease, a structure meant to push attention toward prevention and earlier treatment. Patients previously labeled with mildly reduced ejection fraction now generally fall under the reduced category. That is not a change in their heart function. It is a change in the label, and it may open access to treatments previously recommended with less force.
Foundational Therapy Becomes the New Organizing Idea
The guidelines introduce terminology meant to cut through years of accumulating drug recommendations. Task Force Chair Lars Kober of Rigshospitalet at Copenhagen University Hospital said the older phrase guideline-directed medical therapy had become uncertain in meaning after a decade of new evidence.
Three categories now replace it. Foundational medical therapy covers treatments with the strongest evidence in unselected heart failure patients. Additional medical therapy covers drugs supported for narrower subsets or aimed mainly at symptoms and quality of life. Guideline-directed interventional therapy covers recommended implantable devices and procedures. Kober said the labels are "designed to be dynamic and to remain contemporary over time" as new drugs and devices arrive.
Two therapy updates stand out. Mineralocorticoid receptor antagonists now carry the strongest recommendation class for chronic heart failure regardless of ejection fraction. Semaglutide or tirzepatide, the widely used GLP-1 medicines, receive a moderate recommendation for patients with preserved ejection fraction and obesity. Recommendations were also upgraded for digoxin and digitoxin in chronic heart failure, for durable mechanical circulatory support, and for transcatheter edge-to-edge repair of the mitral valve.
Kober also framed why the burden is expected to grow, pointing to aging populations and the rising prevalence of risk factors and obesity. He said one of the key emphases of the rewrite is prevention and starting treatment as early as possible.
What the Rewrite Asks of Patients
The document includes a section on patient education and self-care, and the society has released a patient version of the guidelines written for people living with the condition rather than for clinicians. Adamo described the goal as equipping patients to be partners in their own care through education, lifestyle advice and shared decision making.
These are European guidelines and do not govern care in the United States, where the American College of Cardiology, American Heart Association and Heart Failure Society of America maintain a separate document. The two bodies of guidance have historically converged over time, but the timing is unpredictable, and no U.S. recommendation has changed because of this publication.
Patients should not adjust or stop medication based on a guideline change. Anyone whose ejection fraction sits near the 50 percent boundary, or who has preserved ejection fraction with obesity, may ask a cardiologist whether the revised framework changes their options. The full text is available through the European Heart Journal listing; the society maintains a heart failure guidelines page collecting the related materials, and the document was presented at the congress on the opening day.
Key Questions Answered
What actually changed? The mildly reduced category was eliminated, reduced ejection fraction now means below 50 percent, preserved means 50 percent or above, acute heart failure was renamed decompensated heart failure, and a four stage model was adopted.
Does this apply to patients in the United States? Not directly. These are European Society of Cardiology guidelines. U.S. cardiology societies publish their own, and no American recommendation has changed because of this document.
Should anyone change their medication? No. Guideline revisions do not constitute individual medical advice. Do not start, stop, or adjust any prescription without speaking to the clinician who manages your care.
What does foundational medical therapy mean? It identifies treatments with the strongest evidence across the general heart failure population, separating them from drugs for narrower groups or symptom relief and from device and procedural therapies.
Who might see their treatment options widen? Patients previously in the mildly reduced band, patients on chronic heart failure treatment who were not receiving a mineralocorticoid receptor antagonist, and patients with preserved ejection fraction and obesity.
Are GLP-1 drugs now recommended for heart failure? Semaglutide and tirzepatide received a moderate recommendation specifically for patients with preserved ejection fraction and obesity, not for heart failure generally.
When will guidance be updated again? The society has not announced a date. It replaced its 2021 guidelines after a focused update in 2023, and says the new therapy categories are built to absorb evidence as it arrives.
