European guidelines for heart failure have changed the classification of the disease: instead of three phenotypes, there will now be two

The European Society of Cardiology has released new 2026 guidelines for the management of patients with heart failure, which significantly change the conventional classification of the disease and simultaneously update approaches to prevention, drug treatment, and interventions. The document was published on August 28, 2026, in the European Heart Journal and presented at the European Society of Cardiology Congress in Munich.

One of the most notable changes is the removal of the separate category of heart failure with moderately reduced ejection fraction. Previously, patients were divided into three main groups based on their left ventricular ejection fraction. Now, only heart failure with reduced ejection fraction (less than 50%) and heart failure with preserved ejection fraction (50% or higher) are distinguished.

The changes extend far beyond terminology. Mineralocorticoid receptor antagonists have received a Class I recommendation for chronic symptomatic heart failure, regardless of ejection fraction. For patients with heart failure with preserved ejection fraction and obesity, the role of weight-loss medications has been significantly strengthened for the first time: semaglutide and tirzepatide have received a Class IIa recommendation. The recommendations for digoxin and digitoxin, mechanical circulatory support, and transcatheter treatment of secondary mitral regurgitation have also been updated.

The authors also want to change the very philosophy of treatment. The new guidelines view heart failure as a continuous process from the risk stage to terminal disease, rather than as a diagnosis that occurs only after the development of shortness of breath and edema. According to working group chair Professor Lars Köber, prevention and the earliest possible initiation of treatment are among the document's central ideas.

Key changes to the 2026 recommendations

Earlier	Recommendations for 2026
Three phenotypes by ejection fraction	Two main phenotypes
Reduced ejection fraction ≤40%	Reduced ejection fraction <50%
Moderately reduced fraction 41-49%	A separate category has been eliminated
Retained fraction ≥50%	Saved: ≥50%
"Acute" heart failure	The term has been replaced by "decompensated"
Guideline-directed medical therapy	New system: basic, additional and interventional therapy
The main focus is on an already developed disease	Stages of AD, starting with prevention
Mineralocorticoid receptor antagonists were phenotype dependent	Class I for symptomatic chronic heart failure regardless of ejection fraction
Limited role of anti-obesity drugs	Semaglutide/tirzepatide - IIa for appropriate phenotype

[1]

Why cardiologists abandoned the separate "moderately reduced" ejection fraction

The left ventricular ejection fraction (LVEF) measures the proportion of blood contained in the ventricle that is ejected with each heartbeat. This metric has been used for decades not only to describe the severity of contractile dysfunction but also to select patients for clinical trials and choose medications. Consequently, LVEF boundaries have gradually become one of the foundations of modern heart failure classification.

The previous system had three categories. Heart failure with reduced ejection fraction was typically defined as values no higher than 40%. The range from 41 to 49% was defined as heart failure with moderately reduced ejection fraction. A value of 50% or higher was defined as heart failure with preserved ejection fraction. A separate intermediate group was created, in part, because such patients had previously been underrepresented in large clinical trials.

In recent years, the situation has changed. According to the working group's co-chair, Associate Professor Marianna Adamo, accumulated data has shown that patients with an ejection fraction of 41-49% are in many ways closer to those with a reduced ejection fraction: they share similar pathophysiological processes and, crucially, can benefit from the same treatments. Therefore, maintaining the artificial cutoff of 40% was becoming less and less consistent with the actual clinical picture.

The new system establishes a much simpler cutoff: if the ejection fraction is less than 50%, heart failure is classified as having a reduced ejection fraction phenotype. If the ejection fraction is 50% or higher, the disease is considered heart failure with preserved ejection fraction. This does not mean that a patient with an ejection fraction of 49% is fundamentally different biologically from a patient with an ejection fraction of 50%. Ejection fraction remains a continuous parameter, but working categories are needed for practical application and the translation of clinical research results.

How has the ejection fraction classification changed?

Left ventricular ejection fraction	Previous classification	ESC 2026 Classification
≤40%	Reduced	Reduced
41-49%	Moderately reduced	Reduced
≥50%	Saved	Saved

[2]

Why ejection fraction is not equal to "percentage of heart work"

The new classification is easily misunderstood. The phrase "45% ejection fraction" doesn't mean the heart is working at only 45% of its capacity. Ejection fraction is the ratio of the volume of blood ejected by the left ventricle during contraction to the volume of blood it held before contraction. It's an important, but far from the only, indicator of cardiac function.

Limitations of this parameter are particularly evident in heart failure with a preserved ejection fraction. In such a patient, the value may be 55-65%, but the ventricle remains too rigid, relaxes poorly, and fills with blood at elevated pressures. As a result, the patient experiences shortness of breath, exercise intolerance, and fluid retention, even with a formally "normal" ability to eject some of the incoming blood. This is why a preserved ejection fraction does not rule out severe heart failure.

Furthermore, ejection fraction measurement is inherently variable. Results depend on the imaging method, image quality, and examination conditions. This is also highlighted in the 2026 Second Universal Definition of Heart Failure: strict cutoff values have limitations, and the ejection fraction itself can change over the course of the disease and with treatment.

Therefore, the new 50% cutoff primarily helps physicians match a specific patient with the evidence base for drug and interventional treatments. A diagnosis of heart failure should still not be based solely on an echocardiogram number: a combination of symptoms, signs of disease, structural or functional changes in the heart, and often an elevated natriuretic peptide level or other objective evidence are required.

What ejection fraction shows—and what it doesn't show

Question	Answer
Shows the proportion of blood ejected by the ventricle?	Yes
Shows "heart health percentage"?	No
Can there be heart failure with a fraction of 60%?	Yes
Is the indicator used to select therapy?	Yes
Is ejection fraction alone sufficient for diagnosis?	No
Can ejection fraction change during treatment?	Yes

Heart failure is now considered in four stages - from risk to severe disease.

At the same time, the European Society of Cardiology is introducing a staging approach to AD, already familiar from American guidelines. Its key difference from traditional functional classes is that the first stages appear before symptomatic heart failure. Thus, prevention becomes a formal part of heart failure treatment.

Stage A signifies an increased risk of heart failure in the absence of structural signs or symptoms. This stage may include people with risk factors such as hypertension, diabetes, chronic kidney disease, obesity, and other conditions that increase the likelihood of future heart damage. The doctor's goal at this stage is not to wait for shortness of breath to develop, but to minimize the likelihood of the disease progressing to the next stage.

Stage B, or pre-existing heart failure, signifies that objective changes have already appeared, but characteristic symptoms are not yet present. These may include structural or functional abnormalities of the heart, or persistent elevations of certain cardiac biomarkers. Stage C corresponds to symptomatic heart failure—the patient has or has previously had characteristic symptoms and objective cardiac changes.

Finally, stage D represents advanced heart failure, when the disease becomes severe, with repeated hospitalizations, refractory congestion, severe limitation of physical activity, or the need to consider heart transplantation and long-term mechanical circulatory support. The new guidelines particularly emphasize the need to refer these patients to a specialized center promptly, without waiting for irreversible deterioration of organ function.

New stage system

Stage	State	The main task
A	Risk of heart failure, but no heart disease or symptoms	Prevention
B	Objective cardiac changes without symptoms	Prevent symptomatic disease
C	Current or past symptoms of heart failure	Optimal treatment of the disease
D	Advanced heart failure	Specialized methods, mechanical support, transplantation, palliative care

[3]

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

Another significant terminological change concerns conditions requiring emergency care. Previously, the term "acute heart failure" was widely used. In its 2026 guidelines, the European Society of Cardiology is replacing it with the term "decompensated heart failure."

The reason for this change isn't just linguistic. The word "acute" creates the impression that heart failure always worsens suddenly. In practice, decompensation often develops gradually: over several days or weeks, shortness of breath, swelling, weight gain, decreased exercise tolerance, and fluid retention increase until the body is no longer able to compensate for the deteriorating heart function.

At the same time, there are truly sudden and dangerous variants—for example, acute pulmonary edema or cardiogenic shock. Therefore, the new terminology allows us to encompass a wide range of conditions requiring urgent evaluation, without assuming that all of them have an instantaneous onset. This is important for clinical practice: a gradual increase in symptoms should not create the false impression that the patient's condition is less serious.

Treatment for decompensation depends on its physiological variant. In cases of severe congestion, diuretics are used; in certain conditions involving high blood pressure, vasodilators may be used; and in cases of cardiogenic shock, organ perfusion assessment, vasopressors, inotropes, or mechanical circulatory support are required. Therefore, "decompensated heart failure" is not a single condition with a single treatment regimen, but a clinical syndrome with various mechanisms.

What does the new terminology change?

Old term	New term	Why
Acute heart failure	Decompensated heart failure	Deterioration does not necessarily develop suddenly.
Sudden pulmonary edema	It remains a separate severe manifestation.	Requires immediate treatment
Cardiogenic shock	Remains a separate critical condition	Associated with insufficient organ perfusion
Gradual increase in stagnation	Now better reflected by the term "decompensation"	The process can take days or weeks.

A new system of therapy is being introduced to replace the vague “recommended treatment”

In recent years, the term guideline-directed medical therapy—that is, drug therapy in accordance with guidelines—has been widely used in cardiology. However, the number of heart failure treatments has grown rapidly, making it unclear which specific medications should be considered essential at any given time. The working group decided to replace it with a more specific system.

The first category is called foundational medical therapy. It includes methods with the strongest evidence base and Class I recommendations for the relevant patient population. For heart failure with reduced ejection fraction, several complementary drug regimens continue to form the basis: renin-angiotensin system blockade, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors.

The second category is additional medical therapy. This includes medications that have proven benefit for specific subgroups, improve symptoms or quality of life, or have a lower-grade recommendation. This allows for a clear distinction between medications needed by the majority of eligible patients and therapies prescribed for specific clinical characteristics.

The third category is guideline-directed interventional therapy. It includes implantable devices and invasive procedures, such as defibrillators, cardiac resynchronization therapy, and certain transcatheter heart valve interventions. According to Lars Köber, the new terminology is intentionally designed to be dynamic: as evidence evolves, drugs and procedures can be moved from one category to another.

New treatment structure

Category	What does it mean?
Basic drug therapy	Methods with the strongest evidence for a broad relevant patient population
Additional drug therapy	Drugs for specific phenotypes, subgroups, or symptom control
Recommended interventional therapy	Devices, catheters and other interventional methods

[4]

Mineralocorticoid receptor antagonists have received a significantly broader role

One of the most clinically important changes concerns mineralocorticoid receptor antagonists. These drugs block the effects of aldosterone and can reduce sodium retention, pathological cardiac remodeling, and other processes that contribute to the progression of heart failure. Traditional agents include spironolactone and eplerenone, and a newer candidate is the nonsteroidal antagonist finerenone.

In the 2026 guidelines, mineralocorticoid receptor antagonists received a Class I recommendation for symptomatic chronic heart failure, regardless of ejection fraction. This is particularly important for patients with preserved ejection fraction, as historically, there have been significantly fewer treatments for this form of the disease capable of improving long-term cardiovascular outcomes.

In practice, this does not mean that the same drug should automatically be prescribed to all patients. The choice of a specific mineralocorticoid receptor antagonist depends on the disease phenotype, the evidence base, renal function, potassium levels, and other characteristics. In particular, new data have significantly strengthened the position of finerenone in heart failure with preserved ejection fraction.

Safety remains a key concern. Drugs in this class can increase blood potassium levels and affect kidney function, so treatment requires laboratory monitoring and consideration of contraindications. The new, high recommendation reflects the strength of the evidence for appropriate patients, rather than the ability to use such drugs without a physician's assessment.

What does recommendation class mean?

Class	Practical meaning
I	Method recommended/indicated: evidence or expert consensus strongly suggests benefit
IIa	The method should be considered: the data rather speak in favor of its use
IIb	The method can be considered, but the evidence is less certain
III	The method is not recommended or may be harmful.

Semaglutide and tirzepatide are included in guidelines for obese heart failure for the first time.

Obesity is increasingly viewed not just as a comorbidity, but as a key factor in a distinct cardiometabolic phenotype of heart failure with preserved ejection fraction. In these patients, excess adipose tissue is associated with inflammation, increased circulating blood volume, increased cardiac workload, vascular dysfunction, and a significant reduction in physical capacity.

For the first time, the new guidelines explicitly include modern weight-loss medications in the heart failure algorithm. Semaglutide and tirzepatide have received a Class IIa recommendation for patients with preserved ejection fraction and obesity. A more detailed version of the guidelines specifies patients with an ejection fraction of approximately 45% and a body mass index of at least 30 kilograms per square meter.

This change isn't simply based on the ability of these drugs to reduce body weight. Clinical trials in recent years have shown improvements in heart failure symptoms, physical function, and quality of life in obese patients with a corresponding disease phenotype. Therefore, obesity treatment is increasingly becoming part of a cardiology strategy rather than a standalone recommendation to "lose weight."

However, a Class IIa recommendation does not mean that all patients with heart failure should receive semaglutide or tirzepatide. This recommendation is based on the specific clinical phenotype, and contraindications, tolerability, concomitant diabetes, gastrointestinal adverse events, nutritional status, and other factors must be considered. The key change is the recognition that targeted treatment of obesity can be part of the treatment of heart failure itself.

What has changed for obese patients?

Parameter	Recommendations 2026
Heart failure with preserved ejection fraction + obesity	It stands out as an important therapeutic phenotype
Semaglutide	Class IIa
Tirzepatide	Class IIa
Main objectives	Weight loss, symptom reduction, improved functional status and quality of life
Prescription for all patients with heart failure	No

[5]

Updated recommendations for digoxin, devices, and treatment of mitral regurgitation

The new guidelines also place greater emphasis on digoxin and digitoxin. These drugs have been known in cardiology for over a century, but their role has shifted as modern treatments emerged. The 2026 document upgrades their recommendations in certain clinical situations, primarily in patients with symptomatic heart failure with reduced ejection fraction despite basic therapy.

The approach to advanced heart failure has also been significantly strengthened. If, despite optimal therapy, a patient experiences repeated hospitalizations, severe congestion, deteriorating organ function, or severely limited physical capacity, recommendations recommend early consultation with a specialized heart failure center. This allows for timely consideration of heart transplantation or long-term mechanical circulatory support.

Recommendations for long-term mechanical circulatory support have also been updated. Modern implantable pumps can be used in carefully selected patients as a bridge to transplantation or as long-term treatment when transplantation is not possible. The main idea behind the new recommendations is not to wait until terminal multiple organ failure occurs, as delayed referral significantly limits the availability of high-tech treatment.

A separate change concerns transcatheter edge-to-edge mitral valve repair for secondary mitral regurgitation. For well-selected patients, the recommendation has been strengthened. The procedure reduces backflow through the mitral valve without traditional open surgery, but its effectiveness is highly dependent on proper patient selection and prior optimization of medical therapy.

Other notable changes

Method	What has changed?
Digoxin/digitoxin	Recommendations strengthened for certain patients
Long-term mechanical circulatory support	A more prominent role
Referral to an advanced heart failure center	The early direction is emphasized
Transcatheter treatment of secondary mitral regurgitation	The recommendation is strengthened in carefully selected patients.
Palliative care	Becoming a full-fledged part of the management of severe heart failure

[6]

Why prevention became one of the central themes of the document

Despite significant advances in treatment, heart failure remains a disease with a grave prognosis. According to data cited by the European Society of Cardiology in its guidelines, the prevalence of the syndrome is approximately 1-3% of the adult population, and less than 60% of patients are alive five years after diagnosis. Mortality rates have improved over the past three decades.

An aging population means that the absolute number of patients will increase even with improved individual treatment. This is compounded by the rising prevalence of obesity and other risk factors. Therefore, treatment of stage C—symptomatic heart failure—is not sufficient alone to halt the increasing global burden of the disease.

The AD staging system effectively forces doctors to seek interventions years before the first hospitalization. Control of blood pressure, diabetes, obesity, and chronic kidney disease becomes part of the heart failure prevention strategy. If asymptomatic structural heart changes have already appeared—stage B—the intensity of prevention should be increased.

This is likely one of the most fundamental changes to the guidelines. Modern cardiology is gradually shifting from a model of "treating when the heart fails" to a model of preventing a person from progressing from a high-risk group to symptomatic heart failure, and, if the condition has already developed, using methods that influence the prognosis as early as possible. Professor Lars Koeber identified this goal as one of the key messages of the 2026 document.

Heart failure in numbers

Indicator	Meaning
Prevalence among adults	≈1-3%
Survival at 5 years after diagnosis	less than 60%
The main reasons for the expected increase in load	Population aging, obesity, prevalence of risk factors
The main preventive principle of 2026	Initiate intervention before symptomatic heart failure occurs

[7]

What the new guidelines mean for patients

For someone already diagnosed with heart failure with a "moderately reduced" ejection fraction, the change in designation does not signify a sudden worsening of the condition. For example, a patient with an ejection fraction of 45%, previously classified in a separate intermediate group, is now formally classified as having heart failure with a reduced ejection fraction. What has changed, above all, is the understanding of the evidence base and the patient's place in the treatment algorithm.

The practical advantage of the new classification is that it can reduce therapeutic uncertainty for patients with scores between 41% and 49%. Accumulated research shows that these individuals can benefit from treatments traditionally associated primarily with severely reduced ejection fraction. This has become one of the main arguments against maintaining an intermediate phenotype.

At the same time, more evidence-based options are becoming available to patients with preserved ejection fraction. The role of mineralocorticoid receptor antagonists is expanding, the importance of sodium-glucose cotransporter-2 inhibitors remains high, and in patients with obesity, a separate recommendation is being made for semaglutide or tirzepatide. Thus, a category that until recently was extremely difficult to treat with medications is gradually gaining a more specific therapeutic structure.

However, the new recommendations do not constitute grounds for independent medication changes. The decision depends not only on ejection fraction but also on blood pressure, kidney function, potassium levels, heart rate, the presence of atrial fibrillation, valvular disease, coronary artery disease, diabetes, obesity, and tolerability of therapy. The new classification simplifies treatment conceptually, but does not make it a one-size-fits-all regimen.

Key findings of the new ESC 2026 recommendations

Change	Practical significance
HFrEF is now <50%	The former 41-49% group has been merged with the reduced ejection fraction
HFpEF ≥50%	A distinct phenotype is maintained
HFmrEF removed	Instead of three phenotypes, two are used
AD stages introduced	Prevention becomes part of the heart failure continuum
"Acute HF" → decompensated HF	It is emphasized that the deterioration may be gradual
"Basic drug therapy" was introduced	Therapies with the strongest evidence are more clearly defined
Mineralocorticoid receptor antagonists	Class I for symptomatic chronic heart failure regardless of ejection fraction
Semaglutide/tirzepatide	Class IIa with associated heart failure and obesity
Digoxin/digitoxin	Recommendations have been strengthened in certain situations
Mitral transcatheter mitral valve repair	Strengthened recommendation in selected patients
Advanced heart failure	Earlier referral to specialized centers
Self-monitoring and patient education	Received a special place in the recommendations

News source

Køber L., Adamo M., Ruwald A.-C., Tomasoni D., Anderson L.J., Andersson C., Brugts J.J., Chioncel O., Donal E., Ferdinandy P., Jhund P.S., Leyva F., Lorusso R., Madigan M., Mullens W., Paolillo S., Ryan N., Simpson M., Thiele H., Thune JJ et al. 2026 ESC Guidelines for the management of heart failure: Developed by the task force for the management of heart failure of the European Society of Cardiology, with the special contribution of the Heart Failure Association of the ESC, endorsed by the European Association for Cardio-Thoracic Surgery. European Heart Journal. Published online August 28, 2026. DOI: 10.1093/eurheartj/ehag100.