🫀 ESC HEART FAILURE GUIDELINES 2026 — WHAT HAS CHANGED? The new ESC HF Guidelines bring major changes in classification, treatment, decompensation, devices and precision phenotyping. 🔹 1 | New HF classification ➡️ HFrEF: LVEF <50% ➡️ HFpEF: LVEF ≥50% The previous HFmrEF category is removed. 🔹 2 | “Acute HF” → “Decompensated HF (DHF)” Management focuses on identifying the trigger and rapidly assessing congestion, perfusion, BP, renal function and oxygenation. 🔹 3 | Smarter decongestion IV loop diuretics remain first-line. If response is inadequate, consider sequential nephron blockade with IV acetazolamide or oral hydrochlorothiazide. Early urinary sodium assessment may help guide diuretic escalation. 🔹 4 | Treat before discharge Once stabilized, initiate/optimize foundational therapy—including in-hospital SGLT2 inhibitor initiation. After discharge, aim for rapid optimization, with uptitration generally every 1–2 weeks when tolerated. 🔹 5 | MRA therapy expands MRAs now have a broader role across the EF spectrum, including selected patients with HFpEF. And if EF improves? ➡️ Continue foundational therapy. 🔹 6 | HFpEF becomes increasingly treatable Beyond SGLT2 inhibitors, treatment now includes broader use of MRAs and selected RAAS inhibition, alongside phenotype-driven management of comorbidities. 🔹 7 | CRT: refined selection and timing CRT remains Class I A for symptomatic HFrEF with: ➡️ LVEF ≤35% ➡️ sinus rhythm ➡️ LBBB ➡️ QRS ≥150 ms despite optimal foundational therapy. In this strong electrical phenotype, CRT planning may begin alongside initiation of foundational therapy, with reassessment before implantation. ⚠️ Evidence remains insufficient to recommend conduction-system pacing as an alternative to CRT in HFrEF. 🔹 8 | ICD: more individualized Primary prevention: ➡️ Ischaemic HFrEF, LVEF ≤35% → Class I ➡️ Non-ischaemic HFrEF, LVEF ≤35% → Class IIa Consider competing mortality, comorbidities, frailty, life expectancy and patient preference. 🔹 9 | Obesity becomes a treatment target In selected symptomatic HF with LVEF ≥45% and BMI ≥30 kg/m², semaglutide or tirzepatide should be considered to improve weight, symptoms, exercise capacity and QoL. 🔹 10 | Precision imaging & aetiology The focus moves beyond EF toward identifying why the patient has HF, with greater roles for CMR, CT, nuclear imaging and genetic testing. ATTR-CM therapy also expands to tafamidis, acoramidis and vutrisiran. 🔹 11 | Mitral TEER & haemodynamic monitoring Mitral TEER receives a Class I recommendation in appropriately selected HFrEF with severe secondary MR despite optimized therapy/CRT. Pulmonary artery pressure-guided monitoring is strengthened to Class IIa in selected high-risk patients. 📌 The ESC HF 2026 message: Diagnose earlier → phenotype better → decongest effectively → start treatment early → titrate rapidly → personalize devices and interventions → prevent the next decompensation. 💡 HF management is becoming less about treating an EF number—and more about treating the individual patient’s phenotype, aetiology, haemodynamics and comorbidities. #ESCCongress #HeartFailure #Cardiology #HFrEF #HFpEF #CRT #SGLT2i #CardiacImaging