2026 ESC Guidelines for the Diagnosis and Management of Heart Failure With Reduced Ejection Fraction

The 2026 ESC Guidelines for the Management of Heart Failure, published on 28 August 2026, have substantially changed the terminology and treatment framework compared with the 2016 guideline. In particular, HFmrEF has been removed, and HFrEF now includes patients with LVEF <50%. 

2026 ESC Guidelines for the Diagnosis and Management of Heart Failure With Reduced Ejection Fraction

The 2026 European Society of Cardiology (ESC) Guidelines for the Management of Heart Failure introduce important changes in the definition, classification, diagnosis and treatment of heart failure. Published in August 2026, the guideline simplifies the traditional heart-failure phenotype classification, introduces stages of heart failure from A to D, and establishes a new framework for pharmacological and interventional treatment.

One of the most important changes is the redefinition of heart failure with reduced ejection fraction (HFrEF). The previous distinction between HFrEF and HFmrEF has been removed. In the 2026 ESC guideline, HFrEF is defined as heart failure with a left ventricular ejection fraction (LVEF) below 50%.

This change has major implications for clinical practice because patients with an LVEF of 41–49%, previously classified as HFmrEF, are now included within the HFrEF phenotype.

What Is New in the 2026 ESC Heart Failure Guideline?

The 2026 guideline introduces several major changes:

- HFrEF is now defined as LVEF <50%.

- HFmrEF has been removed as a separate phenotype.

- HFpEF is defined as LVEF ≥50% with evidence supporting the diagnosis.

- A four-stage classification of heart failure has been adopted: Stage A, B, C and D.

- The term "acute heart failure" has been replaced by "decompensated heart failure."

- Guideline-directed medical therapy has been reorganized into foundational medical therapy (FMT) and additional medical therapy (AMT).

- SGLT2 inhibitors and MRAs have important roles across the heart-failure spectrum.

- Foundational treatment for HFrEF includes ACE inhibitors/ARNI/ARBs, beta-blockers, MRAs and SGLT2 inhibitors.

- Rapid initiation and uptitration of foundational therapy is emphasized.

- Therapy should generally be continued even when patients become asymptomatic or their LVEF improves.

New Classification of Heart Failure According to LVEF

The 2026 ESC guideline simplifies the previous three-phenotype system.

HFrEF

HFrEF is defined as:

LVEF <50% + current or previous symptoms and/or signs of heart failure

This means that patients who would previously have been classified as HFmrEF with an LVEF of 41–49% are now included within HFrEF.

HFpEF

HFpEF is defined as:

LVEF ≥50% + symptoms/signs of heart failure + objective evidence of cardiac structural or functional abnormality

Therefore, an LVEF ≥50% alone does not establish the diagnosis of HFpEF.

Why Was HFmrEF Removed?

The 2016 and 2021 ESC guidelines used separate categories for HFrEF, HFmrEF and HFpEF.

The 2026 guideline recognizes that patients with LVEF in the 40–49% range share important clinical and pathophysiological characteristics with HFrEF.

The ESC therefore adopted a single 50% threshold:

HFrEF: LVEF <50%

HFpEF: LVEF ≥50%

The purpose is to simplify clinical classification and better reflect similarities in underlying disease and treatment response.

Stages of Heart Failure: A–D

Another major change is the introduction of a stage-based framework.

Stage A — At Risk for Heart Failure

Patients have risk factors for developing heart failure but do not have:

- Signs or symptoms of HF

- Structural cardiac abnormalities

- Established HF

Risk factors may include:

- Hypertension

- Diabetes mellitus

- Obesity

- Coronary artery disease

- Chronic kidney disease

- Cardiometabolic disease

- Exposure to cardiotoxic therapies

- Genetic predisposition

The emphasis at this stage is prevention.

Stage B — Pre-HF

Stage B refers to patients who have evidence of cardiac disease or abnormalities but do not currently have symptoms or signs of heart failure.

Examples include:

- Structural heart disease

- Reduced or abnormal ventricular function

- Elevated cardiac biomarkers in appropriate contexts

- Other objective evidence of cardiac involvement

The objective is early identification and intervention before symptomatic HF develops.

Stage C — Symptomatic Heart Failure

Stage C represents established symptomatic heart failure.

It includes patients with:

- Current or previous symptoms and/or signs of HF

- Objective evidence of cardiac abnormality

Most patients diagnosed clinically with HFrEF fall into Stage C.

Stage D — Advanced Heart Failure

Stage D represents advanced heart failure despite appropriate treatment.

These patients may require consideration of:

- Advanced pharmacological therapy

- Mechanical circulatory support

- Heart transplantation

- Palliative and supportive care

The stage-based approach places much greater emphasis on prevention and early intervention.

Diagnosis of HFrEF

The diagnosis of HFrEF requires clinical evidence of heart failure together with reduced LVEF.

The 2026 ESC guideline states that HFrEF requires:

1. Current or previous symptoms and/or signs of HF

2. LVEF <50%

Natriuretic peptides can provide additional diagnostic support, particularly when echocardiography is not immediately available.

However, natriuretic peptide levels must always be interpreted in clinical context because several conditions can increase or decrease their concentrations.

Echocardiography

Echocardiography remains central to the diagnosis and phenotyping of heart failure.

Important parameters include:

- LVEF

- LV dimensions

- LV systolic function

- RV function

- Chamber dimensions

- Diastolic function

- Valvular disease

- Pulmonary pressures

- Pericardial disease

- Regional wall-motion abnormalities

Echocardiography also helps identify the underlying aetiology of HFrEF.

Search for the Aetiology

Identifying the cause of HFrEF remains essential because some causes are potentially reversible or specifically treatable.

Important causes include:

- Ischaemic heart disease

- Hypertension

- Valvular heart disease

- Dilated cardiomyopathy

- Inflammatory cardiomyopathy

- Myocarditis

- Tachycardia-mediated cardiomyopathy

- Genetic cardiomyopathies

- Cardiac amyloidosis and other infiltrative diseases

- Alcohol-related cardiomyopathy

- Chemotherapy-related cardiotoxicity

- Endocrine disorders

- Nutritional deficiencies

The 2026 guideline specifically emphasizes aetiological assessment as part of the diagnostic process.

Foundational Medical Therapy in HFrEF

One of the most important changes in terminology is the introduction of the concept of Foundational Medical Therapy (FMT).

For HFrEF, foundational therapy consists of four major drug classes:

1. ACE inhibitor/ARNI/ARB

2. Evidence-based beta-blocker

3. Mineralocorticoid receptor antagonist

4. SGLT2 inhibitor

The guideline emphasizes that there is no evidence that one specific sequence of initiation is universally superior.

Instead, treatment can be started and individualized according to the patient's clinical status.

The major principle is:

Start foundational therapy early and optimize it rapidly.

1. ACE Inhibitors, ARNI and ARBs

Renin–angiotensin system inhibition remains an important component of HFrEF treatment.

The 2026 guideline includes:

- ACE inhibitors

- ARNI

- ARBs

within foundational medical therapy for HFrEF.

Sacubitril/valsartan provides combined neprilysin inhibition and angiotensin-receptor blockade and remains an important treatment option.

ACE inhibitors remain an established treatment option, while ARBs are particularly relevant when ACE inhibitors are not tolerated.

Treatment should be individualized according to:

- Blood pressure

- Renal function

- Potassium

- Previous treatment

- Tolerability

- Clinical status

2. Beta-Blockers

Evidence-based beta-blockers remain foundational therapy for HFrEF.

Important evidence-based agents include:

- Bisoprolol

- Carvedilol

- Metoprolol succinate

- Nebivolol in appropriate patients

Beta-blockers reduce adverse cardiovascular outcomes and are an essential component of disease-modifying therapy.

They should be initiated and titrated according to clinical stability, blood pressure, heart rate and volume status.

3. Mineralocorticoid Receptor Antagonists

The 2026 ESC guideline gives MRAs a particularly prominent role.

An MRA is recommended in symptomatic heart failure independent of LVEF to reduce the risk of heart-failure hospitalization or cardiovascular death.

For HFrEF, steroidal MRAs such as:

- Spironolactone

- Eplerenone

remain important therapies.

Renal function and serum potassium must be monitored because hyperkalemia is an important potential adverse effect.

4. SGLT2 Inhibitors

SGLT2 inhibitors are now a fundamental component of heart-failure therapy.

The 2026 ESC guideline recommends an SGLT2 inhibitor in symptomatic heart failure independent of LVEF to reduce the risk of heart-failure hospitalization or cardiovascular death.

The principal agents are:

- Dapagliflozin

- Empagliflozin

This represents an important evolution in heart-failure management because SGLT2 inhibitors are no longer viewed primarily as diabetes medications. Their cardiovascular benefits extend across different heart-failure phenotypes.

The Four Pillars of HFrEF Therapy

For practical clinical use, the foundational HFrEF regimen can be remembered as:

1. ARNI/ACE-I/ARB

+ 

2. Evidence-based beta-blocker

+ 

3. MRA

+ 

4. SGLT2 inhibitor

This four-drug strategy represents the core disease-modifying pharmacological treatment of HFrEF in the 2026 ESC guideline.

Rapid Uptitration of Therapy

The 2026 guideline places strong emphasis on rapid optimization.

Uptitration of foundational medical therapy at least every 1–2 weeks, when clinically appropriate, is recommended and should be guided by:

- Symptoms

- Blood pressure

- Heart rate

- Renal function

- Electrolytes

- Volume status

The aim is to reach evidence-based target doses or the maximum tolerated dose.

Importantly, there is no requirement to completely optimize one drug before starting another.

The guideline supports individualized initiation and optimization of foundational therapy as soon as the diagnosis is established.

Continue Therapy Even When LVEF Improves

An important practical message is that improvement in LVEF does not automatically mean that disease-modifying treatment should be withdrawn.

The 2026 guideline recommends continuation of foundational medical therapy at the highest tolerated doses, including in patients who:

- Become asymptomatic

- Have improved LVEF

- Have apparently recovered ventricular function

This reflects the risk of recurrence or deterioration after withdrawal of effective therapy.

Loop Diuretics

Loop diuretics remain important for patients with clinical congestion.

Examples include:

- Furosemide

- Torsemide

- Bumetanide

The 2026 ESC guideline recommends dynamic individualized dosing according to volume status in patients with signs or symptoms of congestion.

The goal is to:

- Relieve congestion

- Improve symptoms

- Improve exercise capacity

- Reduce the risk of hospitalization

Unlike foundational disease-modifying therapies, loop diuretics are primarily used for decongestion and symptom control.

Additional Medical Therapy

Not every patient requires additional therapy beyond foundational treatment.

The guideline categorizes selected therapies as Additional Medical Therapy (AMT).

These include therapies such as:

- Ivabradine

- Vericiguat

- Hydralazine/isosorbide dinitrate

- Cardiac glycosides

- Cardiac myosin activator therapy in selected circumstances

Their use depends on the clinical phenotype and specific indication.

Ivabradine

Ivabradine remains relevant in selected patients with HFrEF.

It reduces sinus-node firing through inhibition of the If current.

Its role is particularly relevant when patients have:

- Sinus rhythm

- Persistent elevated heart rate

- Reduced LVEF

- Persistent symptoms despite appropriate foundational treatment

The treatment decision should be individualized according to the patient's heart rate, rhythm and beta-blocker tolerance.

Vericiguat

Vericiguat is another additional therapy for selected patients with HFrEF.

It acts through stimulation of the soluble guanylate cyclase pathway.

It may be considered particularly in patients with worsening heart failure despite foundational therapy.

Its role is therefore different from the four foundational drug classes.

Hydralazine and Isosorbide Dinitrate

Hydralazine combined with isosorbide dinitrate remains an option in selected patients.

It may be particularly relevant when:

- Standard renin–angiotensin system inhibition cannot be used

- Specific patient characteristics make this combination appropriate

Its role is not equivalent to the universal foundational therapies.

Cardiac Glycosides

Digoxin and related cardiac glycosides have a more selective role.

The 2026 guideline has upgraded recommendations concerning cardiac glycosides in selected patients compared with previous ESC recommendations.

The decision should take into account:

- Rhythm

- Symptoms

- Renal function

- Drug interactions

- Serum concentration where appropriate

Cardiac Myosin Activator

The 2026 guideline also includes cardiac myosin activator therapy among additional HFrEF treatments.

This reflects the expansion of pharmacological options beyond traditional neurohormonal modulation.

The precise role depends on the patient's phenotype and the evidence applicable to the specific agent.

Device Therapy

Pharmacological therapy is only one component of HFrEF management.

The 2026 ESC guideline continues to emphasize guideline-directed interventional therapy, or GDIT.

This includes:

- Implantable cardioverter-defibrillator therapy

- Cardiac resynchronization therapy

- Selected catheter-based interventions

- Mechanical circulatory support

- Other appropriate interventional therapies

The term GDIT is part of the new nomenclature introduced by the 2026 guideline.

Implantable Cardioverter-Defibrillator

ICD therapy remains important for selected patients with HFrEF at increased risk of sudden cardiac death.

The decision should consider:

- LVEF

- NYHA functional status

- Aetiology

- Duration of optimized medical treatment

- Ventricular arrhythmia history

- Life expectancy

- Comorbidities

- Patient preferences

ICD implantation should therefore be integrated with optimized pharmacological therapy and overall prognosis.

Cardiac Resynchronization Therapy

CRT remains an important intervention for appropriately selected patients with HFrEF and electrical dyssynchrony.

Important parameters include:

- LVEF

- QRS duration

- QRS morphology

- Sinus rhythm versus atrial fibrillation

- NYHA functional status

- Expected pacing requirement

Patients with LBBB and a markedly prolonged QRS generally represent an important group for consideration of CRT.

Decompensated Heart Failure

The 2026 ESC guideline replaces the term acute heart failure with decompensated heart failure.

This reflects the recognition that clinical deterioration may occur gradually rather than always presenting as a sudden acute event.

Some patients with less severe decompensation may potentially be managed outside the hospital in an appropriate setting.

Assessment should focus on:

- Congestion

- Perfusion

- Blood pressure

- Renal function

- Electrolytes

- Precipitating factors

- Response to treatment

Advanced Heart Failure

Stage D represents advanced heart failure.

Patients may have:

- Severe persistent symptoms

- Recurrent HF hospitalization

- Progressive renal dysfunction

- Intolerance of guideline-directed therapy

- Persistent congestion

- Low cardiac output

- Severe functional limitation

Advanced treatment options may include:

- Durable mechanical circulatory support

- Heart transplantation

- Specialized advanced HF management

- Palliative/supportive care

The 2026 guideline has also upgraded recommendations in specific areas involving durable mechanical circulatory support.

Important Comorbidities

The 2026 guideline emphasizes comprehensive management of comorbid conditions.

Important examples include:

- Atrial fibrillation

- Coronary artery disease

- Hypertension

- Diabetes

- Chronic kidney disease

- Obesity

- Iron deficiency and anemia

- Valvular heart disease

- Pulmonary disease

- Sleep-disordered breathing

- Cancer

- Frailty

- Anxiety and depression

Management of HFrEF therefore requires a multidisciplinary approach rather than focusing solely on LVEF.

The 2026 ESC HFrEF Treatment Strategy

A practical approach is:

Confirm HF + LVEF <50%

↓

Determine the underlying aetiology

↓

Start foundational medical therapy

ARNI/ACE-I/ARB

+ 

Evidence-based beta-blocker

+ 

MRA

+ 

SGLT2 inhibitor

↓

Assess volume status

↓

If congested:

Loop diuretic

↓

Rapidly uptitrate foundational therapy

Aim for evidence-based target or maximum tolerated doses.

↓

If persistent symptoms or specific clinical indications:

Additional medical therapy

Consider:

- Ivabradine

- Vericiguat

- Hydralazine/ISDN

- Cardiac glycosides

- Cardiac myosin activator in selected patients

↓

Assess for ICD

↓

Assess for CRT when indicated

↓

If progressive severe disease:

Refer for advanced HF evaluation

Consider:

- LVAD/mechanical circulatory support

- Heart transplantation

- Palliative/supportive care

2026 ESC vs 2016 ESC: Major Differences

Topic| 2016 ESC| 2026 ESC

HFrEF definition| LVEF <40%| LVEF <50%

HFmrEF| 40–49%| Removed

HFpEF| ≥50%| ≥50% + objective evidence

HF stages| Not A–D| Stages A–D

Core terminology| Guideline-directed treatment| FMT + AMT + GDIT

SGLT2 inhibitors| Not part of 2016 framework| Foundational therapy

MRA| HFrEF-focused| Recommended in symptomatic HF independent of LVEF

Decompensation terminology| Acute HF| Decompensated HF

Therapy optimization| Conventional uptitration| Rapid 1–2 weekly optimization emphasized

Improved LVEF| Less explicit| Continue foundational therapy

Advanced HF| Established concept| More structured Stage D framework

The changes reflect the expansion of evidence since 2016 and the ESC's effort to simplify heart-failure classification and treatment terminology.

Key Take-Home Messages

The most important points from the 2026 ESC Heart Failure Guideline for HFrEF are:

1. HFrEF is now LVEF <50%.

2. HFmrEF has been removed as a separate phenotype.

3. HFpEF is LVEF ≥50% plus clinical HF and objective evidence of cardiac abnormality.

4. Heart failure is classified into Stage A–D.

5. Foundational medical therapy for HFrEF consists of:

ARNI/ACE-I/ARB + beta-blocker + MRA + SGLT2 inhibitor

6. SGLT2 inhibitors are recommended in symptomatic HF independent of LVEF.

7. MRA therapy is recommended in symptomatic HF independent of LVEF.

8. Foundational therapy should be initiated early and uptitrated rapidly when clinically appropriate.

9. Loop diuretics are used according to congestion and volume status.

10. Additional therapies such as ivabradine, vericiguat, hydralazine/ISDN and cardiac glycosides have selected indications.

11. ICD and CRT remain important components of guideline-directed interventional therapy.

12. Treatment should generally continue even when patients become asymptomatic or LVEF improves.

13. Aetiological evaluation is essential because potentially reversible causes of HFrEF must be identified.

14. Stage D patients require consideration of advanced HF therapies, including mechanical circulatory support and transplantation.

Conclusion

The 2026 ESC Guidelines represent a major evolution in the management of heart failure. The most striking change is the simplification of the LVEF-based classification: HFrEF now includes patients with LVEF below 50%, while HFmrEF has been removed