2026 ESC Guidelines for the management of heart failure
Presented on the opening day of ESC 2026, this guideline redraws the map its 2021 predecessor established. The mildly-reduced category disappears: HFrEF now runs to an ejection fraction below 50% and HFpEF begins at 50%. "Acute" heart failure becomes "decompensated", guideline-directed medical therapy is split into foundational and additional medical therapy with interventional therapy alongside it, and a stage A–D framework — aligned with the 2022 AHA/ACC/HFSA guideline — carries the document from risk factors to advanced disease. An MRA is Class I at any ejection fraction; semaglutide or tirzepatide enters at Class IIa for symptomatic HF with an ejection fraction of 45% or more and a BMI of 30 or above; a TTR silencer or stabiliser becomes Class I in transthyretin amyloid cardiomyopathy, variant and wild-type alike; and a durable assist device rises from Class IIa to Class I in selected advanced disease. The register's trials are grouped below by the pillars the guideline rests on.
This guideline cites 19 of the 199 landmark trials in our Cardiology register.
Foundational medical therapy9
- 2020EMPEROR-ReducedCardiology · HF · SGLT2 inhibitorsEmpagliflozin Outcome Trial in Chronic Heart Failure With Reduced EF
- 2019DAPA-HFCardiology · HF · SGLT2 inhibitorsDapagliflozin and Prevention of Adverse outcomes in Heart Failure
- 2014PARADIGM-HFCardiology · HF · ARNIProspective comparison of ARNI with ACEI to Determine Impact on Global Mortality
- 2011EMPHASIS-HFCardiology · HF · MRAEplerenone in Mild Patients Hospitalisation and Survival Study in Heart Failure
- 2001COPERNICUSCardiology · HF · beta-blockerCarvedilol Prospective Randomized Cumulative Survival Study
- 1999RALESCardiology · HF · MRARandomized Aldactone Evaluation Study
- 1999MERIT-HFCardiology · HF · Beta-blockadeMetoprolol CR/XL Randomized Intervention Trial in Heart Failure
- 1991SOLVDCardiology · HF · ACE inhibitorStudies of Left Ventricular Dysfunction — Treatment Trial
- 1987CONSENSUSCardiology · HF · RAAS inhibitionCooperative North Scandinavian Enalapril Survival Study
Preserved ejection fraction & incretins6
- 2025SUMMITCardiology · Cardiometabolic · Obesity & HFpEFTirzepatide for Heart Failure with Preserved Ejection Fraction and Obesity
- 2024FINEARTS-HFCardiology · HF · MRAFinerenone in Heart Failure with Mildly Reduced or Preserved Ejection Fraction
- 2023STEP-HFpEFCardiology · HF · GLP-1 RASemaglutide Treatment Effect in People with obesity and HFpEF
- 2022DELIVERCardiology · HF · SGLT2 inhibitorsDapagliflozin Evaluation to Improve the Lives of Patients with Preserved-EF Heart Failure
- 2021EMPEROR-PreservedCardiology · HF · SGLT2 inhibitorsEmpagliflozin Outcome Trial in Patients With Chronic Heart Failure With Preserved EF
- 2014TOPCATCardiology · HF · MRATreatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist
Decompensated heart failure2
- 2022STRONG-HFCardiology · HF · GDMT up-titrationSafety, Tolerability and Efficacy of Rapid Optimization, helped by NT-proBNP testinG, of Heart Failure therapies
- 2019PIONEER-HFCardiology · HF · ARNIComparison of Sacubitril/Valsartan versus Enalapril on Effect on NT-proBNP in Patients Stabilized from an Acute Heart Failure Episode