ESC · 2026

Heart Failure — Management Guideline

Source: 2026 ESC Guidelines for the management of heart failure, European Heart Journal

✓ Edition checked 3 Oct 2026 — ESC 2026 is the current edition as of this date.

Guideline: Strong Guideline: Conditional Guideline: Not recommended ClinicoQ pathway suggestion (not from the cited guideline)

Diagnosis

Diagnostic criteria Heart failure is a clinical syndrome of symptoms and/or signs caused by structural and/or functional cardiac abnormalities that raise intracardiac pressures or reduce cardiac output, with objective evidence of congestion and supportive tests. Phenotypes (ESC 2026): HFrEF = LVEF below 50% plus symptoms and/or signs; HFpEF = LVEF 50% or above plus symptoms and/or signs plus objective evidence of structural/functional abnormality consistent with LV diastolic dysfunction or raised filling pressures, supported by raised natriuretic peptides. HFmrEF (LVEF 41-49%) no longer exists as a separate category. Improved LVEF requires an absolute increase of at least 10% to a value above 40%. Stages: A (at risk), B (pre-HF with structural/functional abnormality or raised natriuretic peptides), C (symptomatic HF), D (advanced HF).

⚠ Alarm features (investigate before diagnosing)

Signs of hypoperfusion: cold extremities, oliguria, confusion, narrow pulse pressure
Acute pulmonary oedema or cardiogenic shock
Weight gain of more than 2 kg per week with worsening dyspnoea (decompensation)
Syncope or symptomatic ventricular arrhythmia

Initial workup

Test	When to order
12-lead ECG and chest X-ray	Part of the initial specialist assessment with clinical evaluation, risk factors, and history.
Natriuretic peptides (NT-proBNP or BNP)	Next step after clinical suspicion, followed by echocardiography. The 2026 text notes that a single rule-out threshold (NT-proBNP below 125 pg/mL in 2021) is simple but nonspecific in older people, and describes age-adjusted levels above which heart failure is likely in the outpatient setting: 125 pg/mL or above under 50 years, 250 pg/mL or above at 50-75 years, and 500 pg/mL or above over 75 years (HFA-ESC consensus); age-specific BNP cut-offs are not available. Check Figure 4 for the formal algorithm. Echocardiography is preferably performed within 2 weeks if NT-proBNP is above 2000 pg/mL. For decompensated HF the rule-out thresholds are NT-proBNP below 300 pg/mL, BNP below 100 pg/mL, or MR-proANP below 120 pg/mL, and the age-related rule-in levels are NT-proBNP above 450 pg/mL (under 50 years), 900 pg/mL (50-74 years), and 1800 pg/mL (over 74 years).
Transthoracic echocardiography	In every patient with suspected HF to measure LVEF and assess structure and filling pressures; LVEF may be falsely high in conditions such as mitral regurgitation.
Invasive coronary angiography	Patients with HF, angina, and high probability of obstructive CAD who are candidates for revascularization.
Contrast-enhanced cardiac MRI	Suspected cardiomyopathy or uncertain aetiology if further characterization is likely to add value; CMR with late gadolinium enhancement is considered in dilated cardiomyopathy to separate ischaemic from non-ischaemic damage.
Serum and urine immunofixation, serum free light chains, and DPD/PYP/HMDP bone scintigraphy	Patients with HF and suspected cardiac amyloidosis.
Genetic testing	Patients fulfilling diagnostic criteria for cardiomyopathy when it enables diagnosis, prognostication, therapeutic stratification, reproductive management, or cascade screening of relatives.

Decision Points

❓ What is the stage and LVEF of the patient?

Asymptomatic: at risk (stage A) or pre-HF (stage B) → Stage A-B (prevention and asymptomatic LV dysfunction)

Symptomatic HF with LVEF below 50% (HFrEF) → HFrEF (LVEF below 50%): foundational medical therapy

Symptomatic HF with LVEF 50% or above (HFpEF) → HFpEF (LVEF 50% or above)

❓ Is the patient decompensated (worsening congestion or hypoperfusion needing hospital care)?

Yes, decompensated heart failure → Decompensated heart failure (hospital)

No, stable chronic heart failure → All patients with heart failure: congestion, exercise, and referral

Treatment

HFrEF (LVEF below 50%): foundational medical therapy

1 ACE-I, ARNI (sacubitril/valsartan), or ARB if unable to tolerate an ACE-I or ARNI Strong (Guideline recommendation) — foundational medical therapy (Class I) for HFrEF

Dose: Sacubitril/valsartan: start 49/51 mg twice daily (an optional lower start of 24/26 mg twice daily may be used in selected patients, for example with symptomatic hypotension or no prior ACE-inhibitor or ARB exposure), target 97/103 mg twice daily. Enalapril target 10 mg twice daily (trial dose)
Duration: Ongoing; uptitrate at least every 1-2 weeks as tolerated
Evidence level: High
Avoid if: Pregnancy; history of angioedema; symptomatic hypotension; hyperkalaemia; severe renal impairment (check labeling); do not combine ACE-I with ARNI (36-hour washout)
If no response: Uptitrate toward target dose every 1-2 weeks as tolerated (ESC 2026, Class I)

2 Beta-blocker (e.g., bisoprolol or carvedilol) Strong (Guideline recommendation) — foundational medical therapy (Class I) for HFrEF

Dose: Bisoprolol target 10 mg once daily; carvedilol start 3.125 mg twice daily, target 25 mg twice daily (up to 50 mg twice daily if body weight is above 85 kg) (trial doses)
Duration: Ongoing; uptitrate at least every 1-2 weeks as tolerated
Evidence level: High
Avoid if: Symptomatic bradycardia or high-degree AV block without a pacemaker; cardiogenic shock; severe decompensation (do not start during hypoperfusion)
If no response: Uptitrate toward target dose every 1-2 weeks as tolerated (ESC 2026, Class I)

3 Mineralocorticoid receptor antagonist (spironolactone or eplerenone) Strong (Guideline recommendation) — Class I, level A in symptomatic HF independent of LVEF

Dose: Spironolactone 25-50 mg once daily; eplerenone target 50 mg once daily (trial doses)
Duration: Ongoing; monitor potassium and creatinine
Evidence level: High
Avoid if: Hyperkalaemia; severe renal impairment (check labeling); pregnancy
If no response: Uptitrate toward target dose every 1-2 weeks as tolerated (ESC 2026, Class I)

4 SGLT2 inhibitor (dapagliflozin or empagliflozin) Strong (Guideline recommendation) — foundational medical therapy (Class I) for HF independent of LVEF

Dose: Dapagliflozin 10 mg once daily or empagliflozin 10 mg once daily (trial doses)
Duration: Ongoing
Evidence level: High
Avoid if: Type 1 diabetes or ketoacidosis risk; eGFR below the labeled threshold; recurrent genital infections; pregnancy
If no response: Continue all four foundational drugs at the highest tolerated doses, even if symptoms resolve or LVEF improves (ESC 2026, Class I)

5 Additional medical therapy if still symptomatic despite optimal foundational therapy (vericiguat, or digoxin/digitoxin) Guideline recommendation (additional therapy): vericiguat may be considered with LVEF below 45% (Class IIb); a cardiac glycoside should be considered with LVEF 40% or below (Class IIa)

Dose: Per product labeling
Duration: Ongoing, reassess
Evidence level: Moderate
Avoid if: Renal impairment and digoxin toxicity risk (check levels); vericiguat with long-acting nitrates or PDE5 inhibitors; pregnancy
If no response ClinicoQ pathway: Refer to a heart failure team for device therapy and advanced HF evaluation

HFpEF (LVEF 50% or above)

1 SGLT2 inhibitor (dapagliflozin or empagliflozin) Strong (Guideline recommendation) — foundational medical therapy (Class I) for HFpEF

Dose: Dapagliflozin 10 mg once daily or empagliflozin 10 mg once daily (trial doses)
Duration: Ongoing
Evidence level: High
Avoid if: Type 1 diabetes or ketoacidosis risk; eGFR below the labeled threshold; pregnancy
If no response ClinicoQ pathway: Add an MRA

2 Mineralocorticoid receptor antagonist (steroidal or non-steroidal) Strong (Guideline recommendation) — Class I, level A in symptomatic HF independent of LVEF

Dose: Per product labeling
Duration: Ongoing; monitor potassium and creatinine
Evidence level: High
Avoid if: Hyperkalaemia; severe renal impairment (check labeling); pregnancy
If no response ClinicoQ pathway: If symptomatic with obesity (BMI 30 kg/m2 or above, LVEF 45% or above), consider semaglutide or tirzepatide

3 Semaglutide or tirzepatide for HF with obesity Guideline recommendation (Class IIa, level B1) — symptomatic HF, LVEF 45% or above, BMI 30 kg/m2 or above, regardless of diabetes status

Dose: Per product labeling
Duration: Ongoing
Evidence level: Moderate
Avoid if: Personal/family history of medullary thyroid carcinoma or MEN2; history of pancreatitis; pregnancy
If no response: ACE-I/ARB/ARNI may be considered to reduce hospitalization (Class IIb, level C)

4 ACE-I, ARB, or ARNI Guideline recommendation (Class IIb, level C) — may be considered to reduce HF hospitalization

Dose: Per product labeling
Duration: Ongoing
Evidence level: Low
Avoid if: Pregnancy; angioedema; hyperkalaemia; symptomatic hypotension

Stage A-B (prevention and asymptomatic LV dysfunction)

1 ACE-I (or ARB if intolerant) and beta-blocker for stage B with reduced LVEF Strong (Guideline recommendation) — ACE-I/ARB if LVEF 40% or below (Class I, level A); beta-blocker if LVEF below 50% (Class I, level B1); eplerenone after MI with LVEF 40% or below and signs of HF or diabetes (Class I, level B1)

Dose: Per product labeling, titrated as for HFrEF
Duration: Ongoing
Evidence level: High
Avoid if: Pregnancy; angioedema; hyperkalaemia; bradycardia or high-degree AV block

2 Risk-factor control to prevent progression Guideline recommendation — SBP below 130 mmHg in hypertension or stage B HF (Class I, level A); SGLT2 inhibitor in T2DM at risk of HF (Class I, level A); finerenone in T2DM with CKD (Class I, level A); statin considered (Class IIa, level A); GLP-1 RA considered in T2DM with another CV risk factor (Class IIa, level A)

Dose: Systolic blood pressure target below 130 mmHg; SGLT2 inhibitor for type 2 diabetes with HF risk; finerenone for type 2 diabetes with CKD; statin for high ASCVD risk
Duration: Ongoing
Evidence level: High
Avoid if: Per individual drug labeling

Decompensated heart failure (hospital)

1 Loop diuretic decongestion, with short-term IV acetazolamide or oral hydrochlorothiazide if fluid overload persists Guideline recommendation — adding short-term IV acetazolamide or oral hydrochlorothiazide is Class IIa, level B1 in fluid overload previously treated with loop diuretics; urinary sodium-guided diuretic therapy may be considered (Class IIb, level B1)

Dose: Per product labeling, titrated to decongestion
Duration: Until euvolaemia
Evidence level: Moderate
Avoid if: Hypotension; hypokalaemia or hyponatraemia; severe renal impairment
If no response ClinicoQ pathway: Start an SGLT2 inhibitor in hospital after initial stabilization

2 In-hospital initiation of an SGLT2 inhibitor after initial stabilization Strong (Guideline recommendation) — Class I, level B1: improves quality of life and congestion symptoms and reduces HF hospitalization

Dose: Dapagliflozin 10 mg once daily or empagliflozin 10 mg once daily (trial doses)
Duration: Continue after discharge
Evidence level: High
Avoid if: Ketoacidosis risk; severe renal impairment (check labeling)
If no response ClinicoQ pathway: Begin cardiac rehabilitation as soon as safely possible

3 Cardiac rehabilitation as soon as safely possible Guideline recommendation (Class IIa, level B1) — to improve functional capacity and quality of life

Dose: —
Duration: Starts in hospital or soon after discharge
Evidence level: Moderate
Avoid if: Unstable condition; per exercise contraindications

All patients with heart failure: congestion, exercise, and referral

1 Personalized exercise training or exercise-based cardiac rehabilitation Strong (Guideline recommendation) — Class I, level B1: recommended for all stable patients unless contraindicated; improves exercise capacity and quality of life and reduces all-cause hospitalization

Dose: —
Duration: Long-term
Evidence level: Moderate
Avoid if: Specific contraindications to exercise training
If no response ClinicoQ pathway: Refer early to an advanced HF centre if advanced HF is suspected

2 Early consultation with an advanced HF centre Strong (Guideline recommendation) — Class I, level A: in patients with advanced HF or at risk of advanced HF, who are motivated and have no absolute contraindication to transplantation or durable mechanical support

Dose: —
Duration: At identification
Evidence level: Moderate
Avoid if: Absolute contraindications for heart transplantation or durable mechanical circulatory support

✕ Treatments the guideline advises against

ACE-I, ARB, ARNI, MRA, ivabradine, or SGLT2 inhibitor during pregnancy: ESC 2026 gives a Class III recommendation against these drugs in pregnancy because of foetotoxicity or teratogenicity. Non-selective beta-blockers should be switched to beta1-selective blockers (metoprolol or bisoprolol).

Temporary mechanical circulatory support in unselected patients with cardiogenic shock after acute MI: ESC 2026 gives a Class III recommendation against this because of the risk of harm.

Intra-aortic balloon pump in unselected patients with cardiogenic shock: ESC 2026 gives a Class III recommendation against it because of the lack of effect.

⚠️ This is an educational summary of current international clinical practice guidelines and does not replace individualized clinical judgment. Final treatment decisions remain the responsibility of the treating physician.