Heart Failure: Classification, Diagnosis and Management

Abstract

The 2026 ESC guidelines have reshaped how heart failure is classified and treated. The three ejection fraction phenotypes are reduced to two. HFrEF now covers any LVEF below 50%, and HFpEF begins at 50%, with the mildly reduced band absorbed into HFrEF on the grounds that these patients share its pathophysiology and respond to the same drugs. Treatment is grouped into foundational medical therapy, additional medical therapy, and guideline-directed interventional therapy. Four classes make up the foundational tier, all carrying Class I recommendations: an ACE inhibitor, ARNI or ARB, a beta-blocker, a mineralocorticoid receptor antagonist, and an SGLT2 inhibitor. Two changes matter most in daily practice. Mineralocorticoid receptor antagonists now hold Class I status at any ejection fraction, where previously they stopped at 40%. Semaglutide or tirzepatide reaches Class IIa for preserved ejection fraction with obesity, the first time an anti-obesity agent has entered a heart failure guideline on outcome grounds. This review sets out the revised classification and staging, natriuretic peptide thresholds for diagnosis, the foundational drugs and how fast to titrate them, additional agents for defined subsets, and device and interventional therapy, with class of recommendation stated throughout.