2026 ESC Management of Heart Failure Guideline Now Available

The European Society of Cardiology (ESC) recently released a new, 2026 clinical practice guideline for the management of heart failure. The 2026 version, Management of Heart Failure, updates and replaces the previous version from 2021, The Diagnosis and Treatment of Acute and Chronic Heart Failure.

The new 2026 Management of Heart Failure guideline expanded HFrEF to now include LVEF up to 50%. HFmrEF was removed in this update. HFpEF now includes LVEF from 50% and above. The term acute heart failure was replaced with decompensated heart failure. Additionally, new classifications for interventional and medical therapy were introduced.

Today, we're showcasing the 39 new recommendations alongside a timeline of pharmacological interventions for patients with heart failure that compare the 2026 and 2021 versions side by side. View the full-text version of the 2026 ESC Management of Heart Failure Guideline for the complete look at all the included recommendations in the guideline.

New Recommendations in the 2026 ESC Management of Heart Failure Guideline

Prevention of Heart Failure

• Counseling on healthy lifestyle choices including maintaining a healthy weight, consuming a well-balanced diet, avoiding sedentary behavior, abstaining from smoking and heavy alcohol consumption, as well as counseling against the use of drugs such as cocaine, amphetamines, and anabolic steroids, is recommended for all patients with stage A or B HF to reduce the risk of HF progression.
• A GLP-1 RA should be considered in patients with T2DM and at least one other additional CV risk factor to reduce the risk of HF or CV death.
• An ACE-I or ARB (if intolerant to ACE-I) is recommended in patients with stage B HF and LVEF ≤40% to reduce the risk of HFH and death.
• A beta-blocker is recommended in patients with stage B HF and LVEF <50% to reduce the risk of HFH or death.
• Eplerenone is recommended in patients after myocardial infarction with LVEF ≤40% with signs of HF or diabetes to reduce the risk of HFH or death.

Diagnosis of Chronic Heart Failure

• Initial diagnostic testing with serum and urine immunofixation, serum free light chains assay, and DPD/PYP/HMDP bone scintigraphy is recommended in patients with HF and a suspicion of cardiac amyloidosis.
• Genetic testing is recommended in patients fulfilling diagnostic criteria for cardiomyopathy in cases where it enables diagnosis, prognostication, therapeutic stratification, or reproductive management of the patient, or where it enables cascade genetic evaluation of their relatives who would otherwise be enrolled into long-term surveillance.
• 18F-FDG-PET scanning should be considered for the diagnostic work-up in patients with cardiomyopathy in whom cardiac sarcoidosis is suspected.
• Review of the proportion of RV pacing should be considered in all patients with CIED and de novo or worsening HFrEF.
• Electrical cardioversion as a diagnostic tool may be considered in patients with persistent AF where there is uncertainty about the value of sinus rhythm restoration on symptoms or to assess improvement in left ventricular function.

Management of Chronic Heart Failure

• Uptitration of FMT at least every 1–2 weeks in patients with HF, guided by symptoms, vital signs, and laboratory findings, to achieve optimal target doses shown to be efficacious in RCTs is recommended to reduce the risk of HFH or death.
• Continuation of FMT at the highest tolerated doses is recommended in all patients with HF, including those who become asymptomatic or with LVEF improvement, in order to reduce the risk of HFH and death.
• Gradual discontinuation of FMT under frequent clinical, laboratory, and imaging surveillance may be considered in highly selected patients who are asymptomatic with complete normalization of LV function and volume as well as natriuretic peptide levels after specific treatment of reversible causes of HF, in order to accommodate patient preference.
• ACE-I/ARB/ARNI may be considered in patients with symptomatic HFpEF to reduce the risk of HFH.
• Initiation of FMT and planning for CRT implantation may be considered simultaneously in patients with symptomatic HFrEF, an LBBB with QRS ≥150 ms, and LVEF ≤35% to improve symptoms and reduce morbidity and death, although reassessment of LVEF should be conducted prior to CRT implantation.

Decompensated Heart Failure

• Urinary Na⁺-guided diuretic therapy may be considered during the first days of treatment of patients with DHF to improve natriuresis and diuresis.
• In-hospital initiation of SGLT2-I is recommended in patients with DHF after initial stabilization to improve QoL and congestion symptoms and reduce the risk of HFH.
• A multidisciplinary Shock Team is recommended in potential candidates for temporary MCS to guide the device selection (modality and type) based on patient and HF characteristics.
• Temporary MCS with a microaxial flow pump should be considered in selected patients with cardiogenic shock caused by ST-elevation MI with LV systolic dysfunction and no risk of hypoxic brain injury in order to reduce the risk of death.
• Temporary MCS should be considered in patients with mechanical complications related to MI as a bridge to definitive treatment.
• Temporary MCS is not recommended in unselected patients with cardiogenic shock caused by acute MI, due to risk of harm.

Advanced Heart Failure

• Early consultation with an advanced HF centre is recommended in patients with advanced HF or at risk of advanced HF, who are motivated and do not have absolute contraindications for heart transplantation or durable MCS, in order to evaluate candidacy.
• Downtitration or discontinuation of beta-blockers or ivabradine should be considered in selected patients with advanced HFrEF and evidence of organ hypoperfusion, despite initial treatment, to increase cardiac output and improve symptoms.
• Histopathological examination of explanted heart tissue from LVAD or heart transplantation surgery should be considered in patients with non-ischaemic HF to identify an aetiological diagnosis that may be treatable or facilitate family screening.

Cardiovascular Comorbidities

• Atrioventricular node ablation combined with CRT should be considered in patients with severely symptomatic permanent AF and poor rate control despite medical therapy and at least one HFH to reduce symptoms, physical limitations, recurrent HFH and death.
• Intravenous amiodarone or digoxin may be considered in haemodynamically unstable patients with HFrEF and AF to stabilize the patient and achieve acute control of heart rate.

Non-Cardiovascular Comorbidities

• Semaglutide or tirzepatide should be considered for patients with symptomatic HF, LVEF ≥45%, and BMI ≥30 kg/m², regardless of diabetes status, to reduce body weight, and improve exercise capacity and QoL.
• Bariatric surgery may be considered in obese patients with HF and a BMI ≥35 kg/m² to reduce body weight when repetitive and structured lifestyle changes combined with weight-reducing medications do not result in maintained weight loss.
• Adaptive servo-ventilation may be considered in patients with HFrEF and sleep-disordered breathing with predominant obstructive sleep apnoea to improve sleep quality, health-related QoL, and symptoms.
• Assessment of anxiety, depression and frailty should be considered in patients with HF to support the development of personalized care plans and to identify factors that may contribute to adverse outcomes.

Multidisciplinary Management of Heart Failure

• Personalized exercise training, in the context of multidisciplinary exercise-based cardiac rehabilitation, is recommended for all stable patients, unless there are specific contraindications, in order to improve exercise capacity, and QoL, and reduce the risk of all-cause hospitalization.
• Personalized exercise training outside exercise-based cardiac rehabilitation is recommended for all stable patients on a long-term basis, unless there are specific contraindications, in order to improve exercise capacity and QoL, and reduce the risk of all-cause hospitalization.
• Cardiac rehabilitation is recommended in patients with an LVAD to improve functional capacity and QoL.
• Cardiac rehabilitation should be considered in patients with DHF, as soon as safely possible, to improve functional capacity and QoL.
• Proactive discussion regarding HF trajectory, goals of care, and advance care planning is recommended in patients with advanced HF to facilitate communication on end of life and QoL.
• Access to an integrated HF palliative care multidisciplinary team is recommended for patients in an advanced HF stage to improve QoL and reduce symptom burden.

Specific Conditions

• Pre-conception care and counselling is recommended for patients with HF to facilitate decision-making surrounding HF treatments, pregnancy, contraception, pre-implantation genetic screening, and assisted reproductive therapies.
• In pregnant women with HFrEF, it is recommended that non-selective beta-blockers are switched to beta₁-selective blockers (metoprolol, bisoprolol) with close mother and foetus monitoring to reduce the risk of adverse foetal events and a lower birth weight.’
• ACE-Is, ARBs, ARNIs, MRAs, ivabradine, and SGLT2-Is are not recommended during pregnancy due to the risk of foetotoxicity or teratogenicity.

ESC Pharmacological Interventions for Patients with Heart Failure Timeline Comparison (2021 vs 2026)

The following tables represent side-by-side comparisons of provided evidence-based doses from the 2021 ESC guideline compared with the 2026 guideline. Notable differences are highlighted in bold.

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