Updated ESC Heart Failure Guideline Brings Big Changes

In updated heart failure guidelines, the European Society of Cardiology (ESC) provides clarity on what goes into guideline-directed medical therapy (GDMT) and scraps heart failure with mildly reduced ejection fraction (HFmrEF) as a category, among other noteworthy changes.

To account for the growing number of therapies available to treat HF, the document now breaks the options down into foundational medical therapy (FMT), additional medical therapy (AMT), and guideline-directed interventional therapy (GDIT).

“One of the biggest problems in heart failure is underuse of drugs, and underuse can be you never give it or you give it in a dosage that’s too low,” Lars Køber, MD (Rigshospitalet and Herlev-Gentofte Hospital, Copenhagen, Denmark), who chaired the document along with Marianna Adamo, MD (University of Brescia, Italy), told TCTMD. “So we tried to make a system where you have something that, in principle, everyone should have, and that is what we define as the foundational medical therapy.”

FMT includes drugs subject to class I recommendations that have been shown to improve morbidity, mortality, or both. It encompasses quadruple therapy with a beta-blocker, a renin-angiotensin-aldosterone system (RAAS) inhibitor, a mineralocorticoid receptor antagonist (MRA), and a sodium-glucose cotransporter 2 (SGLT2) inhibitor for patients with HF with reduced ejection fraction (HFrEF) and an MRA and an SGLT2 inhibitor for those with HF with preserved ejection fraction (HFpEF).

FMT, specifically, can be dynamic, Køber noted. “What is not foundational [this] minute can be next year if a new trial comes and says this is good for everyone in principle.”

Other medications with class IIa/IIb recommendations, or class I recommendations with evidence supporting effects on symptoms and quality of life but not morbidity and mortality, are included in AMT. Under the GDIT umbrella are cardiac implantable electronic devices (CIEDs) and other interventional therapies that have been recommended in the document.

AMT also encompasses other drugs that are not deemed foundational but can be considered for some patients, Køber explained. One example are glucagon-like peptide-1 (GLP-1) receptor agonists, which have a class IIa (level of evidence A) recommendation for consideration in patients with type 2 diabetes and at least one additional CV risk factor to reduce the risk of HF or cardiovascular death.

The recommendations are structured in a more stringent way than in previous guidelines, Køber said. The document “starts by [detailing] what are you going to give, to whom, and why? So what is the treatment? Who is the relevant patient? And what do you expect to obtain? And the last part has sometimes been forgotten,” he said.

What is not foundational [this] minute can be next year if a new trial comes and says this is good for everyone in principle. Lars Køber

Køber said that since the guidelines came out late last month, he has received some questions about why the term GDMT was no longer sufficient, and he explained that there was not full agreement on what was included in that definition. “We realized that people think they agree, but when one says it, it’s not the same as when another doctor says it,” he said.

The new guideline, unveiled recently at the ESC Congress 2026 in Munich, Germany, was published online in the European Heart Journal. It is the first update since 2021 and was developed with the special contribution of the Heart Failure Association of the ESC and endorsed by the European Association for Cardio-Thoracic Surgery.

No More HFmrEF

Køber explained that the writing committee aimed to streamline the definition of HF, eliminating HFmrEF and defining HFrEF as an EF below 50% and HFpEF as an EF of 50% or greater.

“We tried to make it a little more simple because we have been very focused on classification based on ejection fraction, and there were three classes: reduced, mildly reduced, and preserved,” he said. “The middle child, mildly reduced, was problematic because there hadn’t been any trial ever performed in that group for any treatment. It has always been part of those with lower ejection fraction or with those above.”

From a pathophysiological standpoint, “that group seemed to belong in those with reduced ejection fraction,” he continued. “We said, ‘Okay, things that we recommend for heart failure with reduced ejection fraction, that should now be up to just below 50% in ejection fraction.’ So we merged those two groups, and it was basically to make it simpler, [but] it may make some things more complicated because there have been trials going from 40% and above and there have been trials going up to 45%. We had to make some decisions, and we think this is more realistic.”

Defining where a patient belongs based on ejection fraction is challenging, Køber indicated, because of variations in the tools used to measure it, so the document aimed for “a little less focus on ejection fraction.”

It’s important that the diagnosis of HF is not made based on ejection fraction alone, Køber indicated. “If you don’t have any heart failure symptoms, you are not a heart failure patient,” he said. “We wanted to make the distinction clear that if you are going to give the foundational medical therapy, then ensure it is [given to] a heart failure patient.”

That concept of focusing on patients who have the syndrome of HF, he said, “should also be in line with the universal definition of heart failure which came out earlier this year.”

The new document also introduces a staging system borrowed from the latest iteration of the US HF guidelines released in 2022. There are four stages:

• A: at risk for HF but without symptoms of signs of HF, structural cardiac changes, or elevated biomarkers
• B: pre-HF, defined by the lack of current or prior symptoms or signs of HF but with structural abnormalities, impaired cardiac function, or elevated biomarkers
• C: symptomatic HF, defined by having current or prior symptoms and/or signs of HF caused by a structural and/or functional cardiac abnormality, stratified by LVEF into HFrEF (< 50%) or HFpEF (≥ 50%)
• D: advanced HF based on the presence of severe symptoms, impairment of exercise capacity, and cardiac dysfunction, along with recurrent HF events, despite optimal FMT, AMT, and GDIT

Expected Impact

Asked about what impact he hopes the updated guideline will have on practice, Køber said, “I would be very happy if more patients receive the [foundational] quadruple therapy, and faster. If that happens, then it’s a great success.”

There is still reluctance on the part of physicians to get patients started on all four pillars of FMT, he pointed out. “And patients, they do not necessarily want to have more treatment. They would probably prefer to have less. But if they see that this is actually going to make their heart last longer, then I think . . . they’re also willing to do it. And that’s why if we can get more of those four drugs on board early and titrate them to the max dosages, I think we can do a lot.”

One aspect of the new guideline that Køber highlighted was the grading of all recommendations, old and new, using a revised system from the ESC, with two methodologists helping to interpret the data, even for recommendations that had not changed for 5 or 10 years.

“We’ve got help from people who are very good at methodology—that I think is also a virtue of the document,” he said. “That was a healthy process.”