ESC Guidelines 2026: what's new in heart failure, MI definition and CKD
ESC 2026: HFmrEF is removed, HFrEF now includes LVEF up to 50%, the 5th Universal Definition of MI replaces types 1–5, and the first ESC guideline on CKD.
By Medelix EditorialPublished: 4 min read
The headline change of the 2026 ESC guidelines is the new heart failure classification: "HFrEF has been expanded to include LVEF up to 50%", "HFmrEF has been removed", and "HFpEF includes LVEF from 50% and above" ([2]). For 2026 the ESC lists four documents: guidelines on heart failure, cardiac rehabilitation, and cardiovascular disease and chronic kidney disease, plus the Fifth Universal Definition of Myocardial Infarction ([1]). The heart failure, CKD and MI documents were published on 28 August 2026, at ESC Congress 2026 in Munich (28–31 August) ([1], [2], [3], [5]).
As of October 2026. A summary for healthcare professionals. The full texts and their recommendation tables take precedence.
Heart failure 2026: the main changes
According to the "what's new" table of the guideline ([2]):
- LVEF categories: HFrEF now includes LVEF up to 50%, HFmrEF has been removed, and HFpEF begins at an LVEF of 50%.
- "Decompensated HF replaces acute HF."
- Stages A–D have been adopted, "ranging from risk factors to advanced HF". Stage A means at risk of HF; stage B means pre-HF. In asymptomatic patients, LV systolic dysfunction "should be considered present" when LVEF is <50%.
- New therapy nomenclature: foundational medical therapy (FMT), additional medical therapy (AMT) and guideline-directed interventional therapy (GDIT). SGLT2 inhibitors and MRAs are foundational therapies regardless of LVEF.
Selected recommendations (class / level of evidence as given in the guideline)
| Recommendation | Class | Level |
|---|---|---|
| "An MRA (sMRA for HFrEF and sMRA/nsMRA for HFpEF) is recommended in patients with symptomatic HF independent of LVEF" | I | A |
| "In-hospital initiation of SGLT2-I is recommended in patients with DHF after initial stabilization" | I | B1 |
| Uptitration of FMT "at least every 1–2 weeks" | I | C |
| "Continuation of FMT at the highest tolerated doses is recommended in all patients with HF" | I | C |
| ACE inhibitor (or ARB if ACE-I is not tolerated) in stage B HF with LVEF ≤40% | I | A |
| Beta-blocker in stage B HF with LVEF <50% | I | B1 |
| "Semaglutide or tirzepatide should be considered for patients with symptomatic HF, LVEF ≥45%, and BMI ≥30 kg/m2", regardless of diabetes status, to reduce body weight and improve exercise capacity and quality of life | IIa | B1 |
| Bariatric surgery "may be considered" in obese patients with HF and BMI ≥35 kg/m² if structured lifestyle changes plus weight-reducing medication do not keep weight off | IIb | C |
| ACE-Is, ARBs, ARNIs, MRAs, ivabradine and SGLT2-Is during pregnancy | III | C |
The guideline uses a revised evidence framework with levels such as "B1". For the definitions, see the full text ([2]). You can calculate BMI with the BMI calculator.
Fifth Universal Definition of Myocardial Infarction
The 5th UDMI is a joint consensus of the ESC, ACC, AHA and WHF ([1], [3]). Key points:
- The numbered types 1–5 are gone. "The previous numerical classification of myocardial infarction has been replaced." MI is now classified as primary (spontaneous onset of acute myocardial ischaemia), secondary (an alternative acute condition causing supply–demand mismatch) or procedure-related (a complication of a percutaneous or surgical cardiac procedure within 30 days) ([3]).
- Myocardial injury is defined as a rise and/or fall in cardiac troponin with at least one value above the sex-specific 99th percentile upper reference limit (URL) ([3]).
- The document calls using "multiples of the URL to confirm the diagnosis" problematic ([3]).
- MINOCA is now read as "myocardial injury with non-obstructive coronary arteries", "a working rather than final diagnosis" ([3]).
- Dedicated ICD-11 codes support coding ([1], [3]).
For risk stratification of chest pain in the emergency department, see the HEART score.
CVD and chronic kidney disease: the first ESC guideline on the topic
The framework is "STAMP on CKD": Screen, Triage, and Address CKD Risk, Modify CVD management, Plan health services ([4]). Selected points ([5]):
- Screening: "Screening for CKD using eGFR and increased albuminuria is recommended in patients with CVD" (I, C). Albuminuria is assessed with uACR in a spot morning urine sample (I, A). Both eGFR and uACR should be measured twice over at least 3 months (I, C).
- Cystatin C: a cystatin C-based eGFR should be considered when error sources are likely (IIa, A).
- eGFR equation: the guideline notes that the CKD-EPI 2021 equation "was developed for a United States (US) population and overestimates GFR in large parts of Europe" ([5]). Keep this in mind when using any eGFR calculator, including our eGFR (CKD-EPI) calculator.
- Statins: irrespective of lipid levels, an intensive statin-based regimen shown to be safe in CKD for patients with eGFR <60 mL/min/1.73 m² not on kidney replacement therapy (I, A).
- Finerenone in CKD with type 2 diabetes at eGFR ≥25 mL/min/1.73 m² and uACR ≥3 mg/mmol (I, A).
- GLP-1 RA: subcutaneous semaglutide 1.0 mg/week in CKD with type 2 diabetes within defined eGFR/uACR ranges (I, A).
- SGLT2 inhibition is described as recommended at eGFR ≥20 mL/min/1.73 m² and uACR ≥20 mg/mmol (guideline text, section 5.5.2).
Cardiac rehabilitation
The ESC calls this the first ESC guideline dedicated to cardiac rehabilitation ([1]).
Bottom line for practice
Update your documentation templates and local SOPs: the three-way LVEF split is gone, MI types 1–5 are replaced, and CKD screening with eGFR and uACR is recommended for patients with CVD. Before acting on any single recommendation, check the original table, its class and its level of evidence.
Sources
- ESC, Clinical Practice Guidelines (overview 2026): https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines
- 2026 ESC Guidelines for the management of heart failure. Eur Heart J 2026. doi:10.1093/eurheartj/ehag100: https://academic.oup.com/eurheartj/article-lookup/doi/10.1093/eurheartj/ehag100 (guideline page: https://www.escardio.org/guidelines/clinical-practice-guidelines/all-esc-practice-guidelines/heart-failure/)
- Fifth Universal Definition of Myocardial Infarction (2026). Eur Heart J 2026. doi:10.1093/eurheartj/ehag101: https://academic.oup.com/eurheartj/article-lookup/doi/10.1093/eurheartj/ehag101
- ESC, 2026 Guidelines for the management of cardiovascular disease and chronic kidney disease (guideline page): https://www.escardio.org/guidelines/clinical-practice-guidelines/all-esc-practice-guidelines/cvd-chronic-kidney-disease/
- 2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease. Eur Heart J 2026. doi:10.1093/eurheartj/ehag098: https://academic.oup.com/eurheartj/article-lookup/doi/10.1093/eurheartj/ehag098