ESC 2026 2026 ESC Guidelines for the management of heart failure
European Society of Cardiology｜循環器 / 心不全・心筋疾患｜112 ページ｜チャンク 1039｜推奨 184 件｜current
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| 頁 | クラス | レベル | 推奨文 | 表 |
|---|---|---|---|---|
| p.11 | IIa | A | HF or CV death. | Table 5 New recommendations |
| p.11 | I | B1 | A beta-blocker is recommended in patients with stage B HF and LVEF <50% to reduce the risk of HFH or death. | Table 5 New recommendations |
| p.11 | I | B1 | risk of HFH or death. | Table 5 New recommendations |
| p.11 | I | B | Initial diagnostic testing with serum and urine immunofixation, serum free light chains assay, and DPD/PYP/HMDP bone scintigraphy is recommended in patients with HF and a suspicion of cardiac amyloidosis. | Table 5 New recommendations |
| p.11 | IIa | C | sarcoidosis is suspected. | Table 5 New recommendations |
| p.11 | IIa | C | Review of the proportion of RV pacing should be considered in all patients with CIED and de novo or worsening HFrEF. | Table 5 New recommendations |
| p.11 | IIb | C | Electrical cardioversion as a diagnostic tool may be considered in patients with persistent AF where there is uncertainty about the value of sinus rhythm restoration on symptoms or to assess improvement in left ventricular function. | Table 5 New recommendations |
| p.11 | I | C | Uptitration of FMT at least every 1–2 weeks in patients with HF, guided by symptoms, vital signs, and laboratory findings, to achieve optimal target doses shown to be efficacious in RCTs is recommended to reduce the risk of HFH or death. | Table 5 New recommendations |
| p.11 | I | C | Continuation of FMT at the highest tolerated doses is recommended in all patients with HF, including those who become asymptomatic or with LVEF improvement, in order to reduce the risk of HFH and death. | Table 5 New recommendations |
| p.11 | IIb | C | ACE-I/ARB/ARNI may be considered in patients with symptomatic HFpEF to reduce the risk of HFH. | Table 5 New recommendations |
| p.12 | IIb | B1 | Urinary Na+-guided diuretic therapy may be considered during the first days of treatment of patients with DHF to improve natriuresis and diuresis. | |
| p.12 | I | B1 | In-hospital initiation of SGLT2-I is recommended in patients with DHF after initial stabilization to improve QoL and congestion symptoms and reduce the risk of HFH. | |
| p.12 | I | C | A multidisciplinary Shock Team is recommended in potential candidates for temporary MCS to guide the device selection (modality and type) based on patient and HF characteristics. | |
| p.12 | IIa | B1 | Temporary MCS with a microaxial flow pump should be considered in selected patients with cardiogenic shock caused by ST-elevation MI with LV systolic dysfunction and no risk of hypoxic brain injury in order to reduce the risk of death. | |
| p.12 | IIa | C | Temporary MCS should be considered in patients with mechanical complications related to MI as a bridge to definitive treatment. | |
| p.12 | III | B1 | Temporary MCS is not recommended in unselected patients with cardiogenic shock caused by acute MI, due to risk of harm. | |
| p.12 | IIb | C | Intravenous amiodarone or digoxin may be considered in haemodynamically unstable patients with HFrEF and AF to stabilize the patient and achieve acute control of heart rate. | |
| p.12 | IIa | B1 | regardless of diabetes status, to reduce body weight, and improve exercise capacity and QoL. | |
| p.12 | IIb | C | and structured lifestyle changes combined with weight-reducing medications do not result in maintained weight loss. | |
| p.12 | IIb | C | obstructive sleep apnoea to improve sleep quality, health-related QoL, and symptoms. | |
| p.12 | IIa | C | personalized care plans and to identify factors that may contribute to adverse outcomes. | |
| p.12 | I | B1 | Cardiac rehabilitation is recommended in patients with an LVAD to improve functional capacity and QoL. | |
| p.12 | IIa | B1 | Cardiac rehabilitation should be considered in patients with DHF, as soon as safely possible, to improve functional capacity and QoL. | |
| p.12 | I | B1 | Proactive discussion regarding HF trajectory, goals of care, and advance care planning is recommended in patients with advanced HF to facilitate communication on end of life and QoL. | |
| p.12 | I | B2 | Access to an integrated HF palliative care multidisciplinary team is recommended for patients in an advanced HF stage to improve QoL and reduce symptom burden. | |
| p.13 | I | C | Pre-conception care and counselling is recommended for patients with HF to facilitate decision-making surrounding HF treatments, pregnancy, contraception, pre-implantation genetic screening, and assisted reproductive therapies. | |
| p.13 | III | C | or teratogenicity. | |
| p.13 | I | A | prevent or delay the onset of HF, and to prevent HF hospitalizations. | Table 6 Revised recommendations |
| p.13 | I | B | patients with angina despite pharmacological therapy or symptomatic ventricular arrhythmias. | Table 6 Revised recommendations |
| p.13 | I | C | Prevention of heart failure—Section 4 Treatment of hypertension is recommended to Diagnosis of chronic heart failure—Section 5 CMR is recommended for the assessment of myocardial structure and function in those with poor echocardiographic acoustic windows. | Table 6 Revised recommendations |
| p.13 | I | C | CMR is recommended for the characterization of myocardial tissue in suspected infiltrative disease, Fabry disease, inflammatory disease (myocarditis), LV non-compaction, amyloid, sarcoidosis, iron overload/haemochromatosis. | Table 6 Revised recommendations |
| p.13 | IIa | C | CMR with LGE should be considered in DCM to distinguish between ischaemic and non-ischaemic myocardial damage. Invasive coronary angiography is recommended in | Table 6 Revised recommendations |
| p.13 | IIb | B | Invasive coronary angiography may be considered in patients with HFrEF with an intermediate to high pre-test probability of CAD and the presence of ischaemia in non-invasive stress tests. Management of chronic heart failure—Section 6 | Table 6 Revised recommendations |
| p.13 | IIb | C | An MRA is recommended for patients with HFrEF HFmrEF to reduce the risk of HF hospitalization and death. | Table 6 Revised recommendations |
| p.13 | I | A | Strict blood pressure control (systolic blood pressure target <130 mmHg) is recommended in patients with hypertension or stage B HF to reduce the risk of HF. Contrast-enhanced CMR is recommended in patients with suspected cardiomyopathy, or where | Table 6 Revised recommendations |
| p.13 | I | C | the underlying aetiology of HF is uncertain if further characterization is likely to add value to patient care. | Table 6 Revised recommendations |
| p.13 | I | C | Invasive coronary angiography is recommended in patients with HF, angina, and high probability of obstructive CAD who are potential candidates for revascularization. | Table 6 Revised recommendations |
| p.13 | IIa | C | Invasive coronary angiography should be considered in patients with HFrEF and high pre-test likelihood of obstructive CAD, taking into account the risk-to-benefit ratio of the procedures and potential revascularization strategies. HFpEF) is recommended in patients with symptomatic HF independent of LVEF to reduce the risk of HFH or CV death. | Table 6 Revised recommendations |
| p.14 | IIb | B1 | treatment with optimal FMT to reduce the risk of HFH and CV death. | |
| p.14 | III | B1 | with cardiogenic shock, due to the lack of effect. | |
| p.14 | IIa | C | patients with HF-related haemodynamic instability as a BTR, BTD, BTB, BTC, or BTT. | |
| p.14 | IIb | C | evidence of organ hypoperfusion as bridge to MCS or heart transplantation. | |
| p.14 | IIa | B | long-term rate control in patients with HF and AF. | |
| p.14 | IIb | B | Digoxin may be considered in patients with symptomatic HFrEF in sinus rhythm despite treatment with an ACE-I (or ARNI), a beta-blocker and an MRA, to reduce the risk of hospitalization (both all-cause and HF hospitalizations). | |
| p.14 | IIb | B | Vericiguat may be considered in patients in NYHA classes II–IV who have had worsening HF despite treatment with an ACE-I (or ARNI), a beta-blocker and an MRA to reduce the risk of CV mortality and HF hospitalization. [In patients with HFrEF according to the 2021 classification.] | |
| p.14 | I | A | CRT rather than RV pacing is recommended for patients with HFrEF regardless of NYHA class or QRS width who have an indication for ventricular pacing for high degree AV block in order to reduce morbidity. This includes patients with AF. | |
| p.14 | IIa | B | Decompensated heart failure—Section 7 Combination of a loop diuretic with thiazide-type diuretic should be considered in patients with resistant oedema who do not respond to an increase in loop diuretic doses. IABP is not routinely recommended in post-MI | |
| p.14 | IIa | C | Short-term MCS should be considered in patients with cardiogenic shock as a BTR, BTD, BTB. Further indications include treatment of the cause of cardiogenic shock or long-term MCS or transplantation Advanced heart failure—Section 8 Continuous inotropes and/or vasopressors may be considered in patients with low cardiac output and | |
| p.14 | IIa | A | Long-term MCS should be considered in patients with advanced HFrEF despite optimal medical and device therapy, not eligible for heart transplantation or other surgical options, and without severe right ventricular dysfunction, to reduce the risk of death and improve symptoms. | |
| p.14 | IIa | B | medical and device therapy as a bridge to cardiac transplantation in order to improve symptoms, reduce the risk of HF hospitalization and the risk of premature death. Cardiovascular comorbidities—Section 9 Beta-blockers should be considered for short- and | |
| p.14 | IIa | B1 | A cardiac glycoside (digoxin or digitoxin) should be considered in patients with symptomatic HFrEF with LVEF ≤40%, despite optimal FMT, to reduce the risk of HFH. Vericiguat may be considered in patients with symptomatic HFrEF and LVEF <45% despite | |
| p.14 | IIa | B1 | CRT, rather than RV pacing, should be considered in patients with HFrEF regardless of NYHA class or QRS width who have an indication for ventricular pacing for high-degree AV block in order to reduce the risk of HFH and death. | |
| p.14 | IIa | B1 | The addition of short-term intravenous acetazolamide or oral hydrochlorothiazide should be considered in patients with fluid overload previously treated with loop diuretics, to reduce congestion. Temporary MCS should be considered in selected | |
| p.14 | IIa | C | Continuous inotropes should be considered in patients with advanced HFrEF, low cardiac output, and evidence of hypoperfusion or end-organ dysfunction, as BTD, BTT, or as bridge to durable MCS, to increase cardiac output and improve symptoms. Durable MCS (LVAD) is recommended in selected patients with advanced HFrEF, despite FMT and GDIT, as BTT, BTC, BTR, or as destination therapy to improve symptoms and reduce the risk of death. | |
| p.14 | I | C | Beta-blockers are recommended in stable patients with HFrEF and AF as first-line therapy for short- and long-term rate control. | |
| p.15 | I | C | to relieve symptoms. | |
| p.15 | IIa | B | In cases of a clear association between paroxysmal or persistent AF and worsening of HF symptoms, which persist despite MT, catheter ablation should be considered for the prevention or treatment of AF. | |
| p.15 | IIa | C | Coronary revascularization should be considered to relieve persistent symptoms of angina (or an angina-equivalent) in patients with HFrEF, CCS, and coronary anatomy suitable for revascularization, despite OMT including antianginal drugs. | |
| p.15 | I | B | Aortic valve intervention, TAVI or SAVR, is recommended in patients with HF and severe high-gradient aortic stenosis to reduce mortality and improve symptoms. | |
| p.15 | IIa | B | Percutaneous edge-to-edge mitral valve repair should be considered in carefully selected patients with secondary mitral regurgitation, not eligible for surgery and not needing coronary revascularization, who are symptomatic despite OMT and who fulfil criteria for achieving a reduction in HF hospitalizations. | |
| p.15 | IIb | B | Multidisciplinary management—Section 11 Monitoring of pulmonary artery pressure using a wireless haemodynamic monitoring system may be considered in symptomatic patients with HF in order to improve clinical outcomes. | |
| p.15 | I | B | Specific conditions—Section 12 Tafamidis is recommended in patients with genetic testing proven hTTR-CA and NYHA class I or II symptoms to reduce symptoms, CV hospitalization and mortality. | |
| p.15 | I | B | wtTTR-CA and NYHA class I or II symptoms to reduce symptoms, CV hospitalization and mortality. | |
| p.15 | IIa | C | Catheter ablation for AF should be considered in selected patients with symptomatic AF and HFrEF to improve QoL and reduce the risk of HFH or death. Coronary revascularization is recommended in patients with HF, obstructive CAD, and persistent angina, despite FMT for HF and antianginal drugs, | |
| p.15 | I | B1 | Aortic valve intervention, SAVR or TAVI, is recommended in patients with severe aortic stenosis and HF to improve symptoms and reduce the risk of death. | |
| p.15 | I | B1 | Mitral transcatheter edge-to-edge repair is recommended in haemodynamically stable, symptomatic patients with HFrEF and persistent severe secondary mitral regurgitation despite optimized FMT and CRT if indicated, who fulfil specific clinical and echocardiographic criteria, in order to reduce the risk of HFH and improve QoL. | |
| p.15 | IIa | B1 | Remote haemodynamic monitoring of PA pressure should be considered in symptomatic patients with HF, NYHA class III and an HFH in the past 12 months in order to reduce the risk of HFH. Treatment with a TTR silencer (vutrisiran) or stabilizer (tafamidis or acoramidis) for patients with variant or wild-type transthyretin cardiac amyloidosis and NYHA class I–III is recommended to reduce progression of symptoms and the risk of CV hospitalization and all-cause death. | |
| p.19 | I | A | T2DM and CKDd to reduce the risk of HF.105–108 | Recommendation Table 1 — Recommendations for prevention of heart failure (see Evidence Tables 1–15) |
| p.19 | I | A | Strict blood pressure control (systolic blood pressure target <130 mmHg) is recommended in patients with hypertension or stage B HF to reduce the risk of HF.63–69,102 | Recommendation Table 1 — Recommendations for prevention of heart failure (see Evidence Tables 1–15) |
| p.19 | I | A | An SGLT2-I is recommended in patients with T2DM at risk of HF (multiple ASCVD risk factors or established ASCVD) to reduce the risk of HF and CV death.103 | Recommendation Table 1 — Recommendations for prevention of heart failure (see Evidence Tables 1–15) |
| p.19 | I | A | An SGLT2-I is recommended in patients with T2DM and CKDc to reduce the risk of HF or CV death.104 Finerenone is recommended in patients with | Recommendation Table 1 — Recommendations for prevention of heart failure (see Evidence Tables 1–15) |
| p.20 | I | C | Counselling on healthy lifestyle choices including maintaining a healthy weight, consuming a well-balanced diet, avoiding sedentary behaviour, abstaining from smoking and heavy alcohol consumption as well as counselling against the use of drugs such as cocaine, amphetamines, and anabolic steroids is recommended for all patients with stage A or B | |
| p.20 | IIa | A | HF to reduce the risk of HF progression.74,84,85,87,91,95–100,109–112 Treatment with a statin should be considered in people at high risk of, or with established ASCVD, to reduce the risk of HF.75 | |
| p.20 | IIa | A | A GLP-1 RA should be considered in patients with T2DM and at least one other additional CV risk factor to reduce the risk of HF or CV death.71,113,114 | |
| p.21 | I | A | An ACE-I or ARB (if intolerant to ACE-I) is recommended in patients with stage B HF and LVEF ≤40% to reduce the risk of HFH and death.135–138,144 | Recommendation Table 2 — Recommendations for stage B heart failure and left ventricular dysfunction (see Evidence Table 16) |
| p.21 | I | B1 | A beta-blocker is recommended in patients with stage B HF and LVEF <50% to reduce the risk of HFH or death.35,139,140 | Recommendation Table 2 — Recommendations for stage B heart failure and left ventricular dysfunction (see Evidence Table 16) |
| p.21 | I | B1 | Eplerenone is recommended in patients with LVEF ≤40% after myocardial infarction with signs of HF or diabetes to reduce the risk of HFH and death.143 | Recommendation Table 2 — Recommendations for stage B heart failure and left ventricular dysfunction (see Evidence Table 16) |
| p.24 | I | C | suspected HF. | Recommendation Table 3 — Recommendations for diagnostic investigations in all patients with suspected heart failure (see Evidence Tables 17–19) |
| p.24 | I | C | patients with suspected HF. | Recommendation Table 3 — Recommendations for diagnostic investigations in all patients with suspected heart failure (see Evidence Tables 17–19) |
| p.24 | I | C | In patients with suspected HF, the following laboratory tests are recommended when screening for comorbidities: full blood count, kidney function (eGFR and UACR), electrolytes, liver function, thyroid function, HbA1c, lipids, and iron status (TSAT and ferritin).168 | Recommendation Table 3 — Recommendations for diagnostic investigations in all patients with suspected heart failure (see Evidence Tables 17–19) |
| p.24 | I | C | Natriuretic peptide measurement is recommended in patients with suspected HF (interpreted in relation to patient age, obesity, and other factors known to affect natriuretic peptide levelc).146–148,151–153,169 A 12-lead ECG is recommended in patients with | Recommendation Table 3 — Recommendations for diagnostic investigations in all patients with suspected heart failure (see Evidence Tables 17–19) |
| p.24 | I | C | Chest radiography (X-ray) is recommended in Transthoracic echocardiogram is recommended in patients with suspected HF to confirm the diagnosis, differentiate between HF phenotypes and aid in identifying the underlying aetiology of HF. © ESC 2026 | Recommendation Table 3 — Recommendations for diagnostic investigations in all patients with suspected heart failure (see Evidence Tables 17–19) |
| p.30 | I | C | HF is uncertain if further characterization is likely to add value to patient care.205–215 | Recommendation Table 4 — Recommendations for specialized diagnostic investigations in patients with established heart failure to detect reversible/treatable causes of heart failure (see Evidence Tables 20–28) |
| p.30 | I | B | scintigraphy is recommended in patients with HF and a suspicion of cardiac amyloidosis.216–222 | Recommendation Table 4 — Recommendations for specialized diagnostic investigations in patients with established heart failure to detect reversible/treatable causes of heart failure (see Evidence Tables 20–28) |
| p.30 | I | C | Invasive coronary angiography is recommended in patients with HF, angina, and high probabilityc of obstructive CAD who are potential candidates for revascularizationd. | Recommendation Table 4 — Recommendations for specialized diagnostic investigations in patients with established heart failure to detect reversible/treatable causes of heart failure (see Evidence Tables 20–28) |
| p.30 | IIa | C | 18F-FDG-PET scanning should be considered for the diagnostic work-up in patients with cardiomyopathy in whom cardiac sarcoidosis is suspected.181,182 | Recommendation Table 4 — Recommendations for specialized diagnostic investigations in patients with established heart failure to detect reversible/treatable causes of heart failure (see Evidence Tables 20–28) |
| p.30 | IIa | C | congenital heart disease.229 | Recommendation Table 4 — Recommendations for specialized diagnostic investigations in patients with established heart failure to detect reversible/treatable causes of heart failure (see Evidence Tables 20–28) |
| p.30 | IIa | C | taking into account the risk-to-benefit ratio of the procedures and potential revascularization strategies.178–180 | Recommendation Table 4 — Recommendations for specialized diagnostic investigations in patients with established heart failure to detect reversible/treatable causes of heart failure (see Evidence Tables 20–28) |
| p.30 | IIa | C | CTCA should be considered in patients with HFrEF and low-moderate pre-test likelihoodc of obstructive CAD.196,232–234 | Recommendation Table 4 — Recommendations for specialized diagnostic investigations in patients with established heart failure to detect reversible/treatable causes of heart failure (see Evidence Tables 20–28) |
| p.30 | IIa | C | HFrEF.202,235–239 | Recommendation Table 4 — Recommendations for specialized diagnostic investigations in patients with established heart failure to detect reversible/treatable causes of heart failure (see Evidence Tables 20–28) |
| p.30 | IIb | C | the value of sinus rhythm restoration on symptoms or to assess improvement in left ventricular function.240 | Recommendation Table 4 — Recommendations for specialized diagnostic investigations in patients with established heart failure to detect reversible/treatable causes of heart failure (see Evidence Tables 20–28) |
| p.37 | I | A | the risk of HFH or CV death.241–245,326 | Recommendation Table 5 — Recommendations for pharmacological management of chronic heart failure (see Evidence Tables 29–41) |
| p.37 | I | A | LVEF to reduce the risk of HFH or CV death.c43,254–257 | Recommendation Table 5 — Recommendations for pharmacological management of chronic heart failure (see Evidence Tables 29–41) |
| p.37 | I | A | or symptoms of congestion to alleviate HF symptoms, improve exercise capacity, and reduce the risk of HFH.d 327–329 | Recommendation Table 5 — Recommendations for pharmacological management of chronic heart failure (see Evidence Tables 29–41) |
| p.37 | I | C | achieve optimal target doses shown to be efficacious in RCTs is recommended to reduce the risk of HFH or death.274,311 | Recommendation Table 5 — Recommendations for pharmacological management of chronic heart failure (see Evidence Tables 29–41) |
| p.37 | I | C | asymptomatic or with LVEF improvement, in order to reduce the risk of HFH and death.321 | Recommendation Table 5 — Recommendations for pharmacological management of chronic heart failure (see Evidence Tables 29–41) |
| p.37 | I | A | A beta-blocker is recommended in stable patients with symptomatic HFrEF to reduce the risk of HFH and death.e 36,287–293,330 | Recommendation Table 5 — Recommendations for pharmacological management of chronic heart failure (see Evidence Tables 29–41) |
| p.37 | I | A | An ACE-I or ARNI is recommended in patients with symptomatic HFrEF to reduce the risk of HFH and death.e 274–278 | Recommendation Table 5 — Recommendations for pharmacological management of chronic heart failure (see Evidence Tables 29–41) |
| p.37 | I | B1 | and death.e 278 | Recommendation Table 5 — Recommendations for pharmacological management of chronic heart failure (see Evidence Tables 29–41) |
| p.37 | I | A | An ARB is recommended in patients with symptomatic HFrEF to reduce the risk of HFH and CV death if they are unable to tolerate an ACE-I or ARNI.e 284–286,331 | Recommendation Table 5 — Recommendations for pharmacological management of chronic heart failure (see Evidence Tables 29–41) |
| p.37 | IIa | B1 | A cardiac glycoside (digoxin or digitoxin) should be considered in patients with symptomatic HFrEF with LVEF ≤40%, despite optimal FMT, to reduce the risk of HFH.303,304 | Recommendation Table 5 — Recommendations for pharmacological management of chronic heart failure (see Evidence Tables 29–41) |
| p.38 | IIa | B1 | >70 b.p.m., on the highest tolerated ACE-I/ARNI, MRA, SGLT2-I, and beta-blockers to reduce the risk of HFH or CV death.294 | |
| p.38 | IIa | C | a beta-blocker, on the highest tolerated ACE-I/ARNI and MRA to reduce the risk of HFH or CV death.294 | |
| p.38 | IIa | B2 | ≤40% on top of optimal FMT to reduce the risk of HFH and death.300 | |
| p.38 | IIb | C | tolerate ARNI, ACE-I, or ARB to reduce the risk of HFH and death.301 | |
| p.38 | IIb | B1 | reduce the risk of HFH and CV death.295,297,298 | |
| p.38 | IIb | C | ACE-I/ARB/ARNI may be considered in patients with symptomatic HFpEF to reduce the risk of HFH.39,40,42,319,332–337 | |
| p.39 | I | A | An ICD is recommended in patients who have recovered from a ventricular arrhythmia causing haemodynamic instability (secondary prevention), and who are expected to survive for >1 year with good functional status, in the absence of reversible causes, or unless the ventricular arrhythmia has occurred <48 h after an MI, to reduce the risk of sudden death and all-cause death.346 | Recommendation Table 6 — Recommendations for implantable cardioverter-defibrillator implantation (see Evidence Tables 42–48) |
| p.39 | I | B1 | An ICD is recommended in patients with symptomatic HFrEF (NYHA class II/III) of an ischaemic aetiology (unless they have had an MI in the prior 40 days), and an LVEF ≤35% despite ≥3 months of optimal FMT, provided they are expected to survive longer than 1 year with good functional status, to reduce the risk of sudden death and all-cause death.340,342,373,374 | Recommendation Table 6 — Recommendations for implantable cardioverter-defibrillator implantation (see Evidence Tables 42–48) |
| p.39 | IIa | B1 | An ICD should be considered in patients with symptomatic HFrEF (NYHA class II/III) of a non-ischaemic aetiology, and an LVEF ≤35% despite ≥3 months of optimal FMT, provided they are expected to survive longer than 1 year with good functional status, to reduce the risk of sudden death and all-cause death.340,341,344,375 | Recommendation Table 6 — Recommendations for implantable cardioverter-defibrillator implantation (see Evidence Tables 42–48) |
| p.39 | IIa | C | Prior to generator replacement for CIEDs, a shared decision-making process between the patient and a cardiologist experienced in CIEDs and HF should be considered to ensure that the balance between risks and benefits still favour a CIED.376–380 | Recommendation Table 6 — Recommendations for implantable cardioverter-defibrillator implantation (see Evidence Tables 42–48) |
| p.39 | IIb | C | A wearable cardioverter-defibrillator may be considered in patients with HF who are at risk of sudden cardiac death for a limited period in order to increase survival as a bridge to decision for permanent ICD implantation or while listed for heart transplantation.381–384 | Recommendation Table 6 — Recommendations for implantable cardioverter-defibrillator implantation (see Evidence Tables 42–48) |
| p.39 | III | B1 | ICD implantation for primary prevention is not recommended within 40 days of an MI as implantation during this period does not improve prognosis.358,359 | Recommendation Table 6 — Recommendations for implantable cardioverter-defibrillator implantation (see Evidence Tables 42–48) |
| p.39 | III | C | ICD implantation is not recommended in patients in NYHA class IV with severe symptoms refractory to pharmacological therapy unless they are candidates for CRT, a ventricular assist device, or heart transplantation.374,385–387 | Recommendation Table 6 — Recommendations for implantable cardioverter-defibrillator implantation (see Evidence Tables 42–48) |
| p.41 | IIa | B1 | CRT is recommended in patients with symptomatic HFrEF, LVEF ≤35%, despite optimal FMT, in SR with LBBB and QRS duration ≥150 ms in order to improve symptoms and reduce the risk of hospitalizations and death.388– An upgrade to CRT should be considered in patients with an LVEF ≤35% who have received a conventional pacemaker or an ICD and subsequently develop worsening HF despite optimal FMT and who have a significant proportion of RV pacing in order to reduce the risk of HFH or death.412 | Recommendation Table 7 — Recommendations for cardiac resynchronization therapy implantation (see Evidence Tables 49–58) |
| p.41 | IIa | B1 | CRT, rather than RV pacing, should be considered in patients with HFrEF regardless of NYHA class or QRS width who have an indication for ventricular pacing for high-degree AV block in order to reduce the risk of HFH and death.409 | Recommendation Table 7 — Recommendations for cardiac resynchronization therapy implantation (see Evidence Tables 49–58) |
| p.41 | IIa | C | CRT should be considered in patients with symptomatic HFrEF, LVEF ≤35%, despite optimal FMT, who are in SR with non-LBBB QRS morphology and QRS duration ≥150 ms in order to improve symptoms and reduce morbidity and death.388–398 | Recommendation Table 7 — Recommendations for cardiac resynchronization therapy implantation (see Evidence Tables 49–58) |
| p.41 | IIb | C | CRT may be considered in patients with symptomatic HFrEF, LVEF ≤35%, despite optimal FMT, who are in SR with non-LBBB QRS morphology and QRS duration of 130–149 ms in order to improve symptoms and reduce morbidity and death.391,397 | |
| p.41 | IIb | C | Initiation of FMT and planning for CRT implantation may be considered simultaneously in patients with symptomatic HFrEF, an LBBB with QRS ≥150 ms, and LVEF ≤35%, to improve symptoms and reduce morbidity and death, although reassessment of LVEF should be | |
| p.41 | III | A | conducted prior to CRT implantation.418–423 CRT is not recommended in patients with a QRS duration <130 ms who do not have an indication for pacing due to high-degree AV block.410,424,425 | |
| p.47 | I | B2 | 6 weeks following an HFH is recommended to reduce the risk of HF rehospitalization or death.311 | Recommendation Table 8 — Recommendations for pre-discharge and early post-discharge follow-up of patients hospitalized for decompensated heart failure (see Evidence Tables 59–67) |
| p.50 | I | C | Oxygen and ventilatory support Oxygen is recommended in patients with SpO2 <90% or PaO2 <60 mmHg to correct hypoxaemia. | Recommendation Table 9 — Recommendations for the immediate and intermediate treatment of decompensated heart failure (see Evidence Tables 59–67) |
| p.50 | I | C | Intubation is recommended in patients with DHF and persistent and progressive respiratory failure despite oxygen administration or non-invasive ventilation to correct hypoxaemiac. Non-invasive positive pressure ventilation | Recommendation Table 9 — Recommendations for the immediate and intermediate treatment of decompensated heart failure (see Evidence Tables 59–67) |
| p.50 | IIa | B2 | should be considered in patients with respiratory distress (respiratory rate >25 breaths/min, SpO2 <90%) and started as soon as possible in order to decrease respiratory distress and reduce the risk of endotracheal intubation.540 | Recommendation Table 9 — Recommendations for the immediate and intermediate treatment of decompensated heart failure (see Evidence Tables 59–67) |
| p.50 | I | A | Diuretics Intravenous loop diuretics are recommended for all patients with DHF admitted with fluid overload to improve symptomsd. | Recommendation Table 9 — Recommendations for the immediate and intermediate treatment of decompensated heart failure (see Evidence Tables 59–67) |
| p.50 | IIa | B1 | The addition of short-term intravenous acetazolamide or oral hydrochlorothiazide should be considered in patients with fluid overload previously treated with loop diuretics, to reduce congestion.510,511 | Recommendation Table 9 — Recommendations for the immediate and intermediate treatment of decompensated heart failure (see Evidence Tables 59–67) |
| p.50 | IIb | B1 | Urinary Na+-guided diuretic therapy may be considered during the first days of treatment of patients with DHF to improve natriuresis and diuresis.508 | Recommendation Table 9 — Recommendations for the immediate and intermediate treatment of decompensated heart failure (see Evidence Tables 59–67) |
| p.51 | I | B1 | SGLT2-I In-hospital initiation of SGLT2-I is recommended in patients with DHF after initial stabilization to improve QoL and congestion symptoms and reduce the risk of HFH.492,522,525,541 | |
| p.51 | IIb | C | Vasodilators Intravenous vasodilators may be considered as initial therapy in patients with DHF and systolic blood pressure >110 mmHg to improve symptoms and reduce congestion.534 Inotropic agents | |
| p.51 | IIb | C | Inotropic agents may be considered in patients with systolic blood pressure <90 mmHg and evidence of hypoperfusion who do not respond to standard treatment, including fluid challenge, to improve perfusion. | |
| p.51 | IIb | C | Vasopressors Vasopressors, preferably norepinephrine, may be considered in patients with cardiogenic shock to increase blood pressure and vital organ perfusion. | |
| p.51 | III | C | Opiates Routine use of opiates is not recommended in patients with DHF unless severe/intractable pain or anxiety, due to risk of harm.542 | |
| p.52 | I | C | A multidisciplinary Shock Team is recommended in potential candidates for temporary MCS to guide the device selection (modality and type) based on patient and HF characteristics.564,565 Cardiogenic shock caused by acute MI | Recommendation Table 10 — Recommendations for the use of temporary mechanical circulatory support in patients with cardiogenic shock (see Evidence Tables 68 and 69) |
| p.52 | IIa | B1 | Temporary MCS with a microaxial flow pump should be considered in selected patients with cardiogenic shock caused by ST-elevation MI with left ventricular systolic dysfunction and no risk of hypoxic brain injuryc in order to reduce the risk of death.546,549,550 | Recommendation Table 10 — Recommendations for the use of temporary mechanical circulatory support in patients with cardiogenic shock (see Evidence Tables 68 and 69) |
| p.52 | III | B1 | Temporary MCS is not recommended in unselected patients with cardiogenic shock caused by acute MI, due to risk of harm.546,552,553 | Recommendation Table 10 — Recommendations for the use of temporary mechanical circulatory support in patients with cardiogenic shock (see Evidence Tables 68 and 69) |
| p.52 | III | B1 | IABP is not recommended in unselected patients with cardiogenic shock, due to the lack of effect.557,560 | Recommendation Table 10 — Recommendations for the use of temporary mechanical circulatory support in patients with cardiogenic shock (see Evidence Tables 68 and 69) |
| p.52 | IIa | C | MI-related mechanical complications Temporary MCSd should be considered in patients with mechanical complications related to MIe as a bridge to definitive treatment. Advanced HF cardiogenic shock | Recommendation Table 10 — Recommendations for the use of temporary mechanical circulatory support in patients with cardiogenic shock (see Evidence Tables 68 and 69) |
| p.52 | IIa | C | Temporary MCS should be considered in selected patients with HF-related haemodynamic instability as a BTR, BTD, BTB, BTC, or BTT. | Recommendation Table 10 — Recommendations for the use of temporary mechanical circulatory support in patients with cardiogenic shock (see Evidence Tables 68 and 69) |
| p.53 | I | A | © ESC 2026 Early consultation with an advanced HF centrec is recommended in patients with advanced HF or at risk of advanced HF, who are motivated and do not have absolute contraindications for heart transplantation or durable MCSd, in order to evaluate candidacy.e 573,591 | Recommendation Table 11 — Recommendations for diagnosis and evaluation of advanced heart failure (see Evidence Tables 70 and 71) |
| p.53 | I | C | Cardiopulmonary exercise testing is recommended in patients with advanced HF, as part of the evaluation for heart transplantation and durable MCS.579,580,582 | Recommendation Table 11 — Recommendations for diagnosis and evaluation of advanced heart failure (see Evidence Tables 70 and 71) |
| p.54 | I | C | Right heart catheterization is recommended in patients with advanced HF, as part of the evaluation for heart transplantation and durable MCS.580–582 | |
| p.54 | IIa | C | Down-titration or discontinuation of beta-blockers or ivabradine should be considered in selected patients with advanced HFrEF and evidence of organ hypoperfusion, despite initial treatment, to increase cardiac output and improve symptoms. | Recommendation Table 12 — Recommendations for medical management of advanced heart failure (see Evidence Tables 72 and 73) |
| p.54 | IIa | C | Continuous inotropes should be considered in patients with advanced HFrEF, low cardiac output, and evidence of hypoperfusion or end-organ dysfunction, as BTD, BTT or as bridge to durable MCS, to increase cardiac output and improve symptoms.598,599 | Recommendation Table 12 — Recommendations for medical management of advanced heart failure (see Evidence Tables 72 and 73) |
| p.54 | IIa | C | Kidney replacement therapy should be considered in patients with refractory volume overload and end-stage kidney failure to improve symptoms.600 | Recommendation Table 12 — Recommendations for medical management of advanced heart failure (see Evidence Tables 72 and 73) |
| p.54 | IIb | C | Ultrafiltration may be considered in patients with refractory volume overload unresponsive to escalation of diuretic therapy to reduce the risk of rehospitalization.601 | Recommendation Table 12 — Recommendations for medical management of advanced heart failure (see Evidence Tables 72 and 73) |
| p.57 | I | C | Durable MCS (LVAD) is recommended in selectedc patients with advanced HFrEF, despite FMT and GDIT, as BTT, BTC, BTR, or as destination therapy to improve symptoms and reduce the risk of death.604,611,613,620,621 | Recommendation Table 13 — Recommendations for durable mechanical circulatory support in advanced heart failure (see Evidence Table 74) |
| p.57 | IIa | C | Histopathological examination of explanted heart tissue from LVAD or heart transplantation surgery should be considered in patients with non-ischaemic HF to identify an aetiological diagnosis that may be treatable or facilitate family screening.616,618 | Recommendation Table 13 — Recommendations for durable mechanical circulatory support in advanced heart failure (see Evidence Table 74) |
| p.58 | I | C | Heart transplantation is recommended in selectedc patients with advanced HF refractory to FMT and GDIT, and without contraindications, to improve QoL and survival.622,626 | Recommendation Table 14 — Recommendations for heart transplantation (see Evidence Tables 75 and 76) |
| p.59 | I | A | Recommendations for anticoagulation Oral anticoagulation is recommended in patients with clinical AF at elevated thromboembolic risk, as determined by CHA2DS2-VA scorec, to prevent ischaemic stroke and thromboembolism.635 | Recommendation Table 15 — Recommendations for management of atrial fibrillation in patients with heart failure (see Evidence Tables 77–81) |
| p.60 | I | B1 | DOACs are recommended in preference to VKAs in patients with HFd to prevent stroke and thromboembolism.643–646 | |
| p.60 | I | C | Rate control Beta-blockers are recommended in stable patients with HFrEF and AF as first-line therapy for short- and long-term rate control.663,665 Digoxin should be considered in stable patients | |
| p.60 | IIa | C | with HFrEF and AF when the ventricular rate remains high despite beta-blockers, or when beta-blockers are contraindicated/not tolerated, in order to obtain short- and long-term rate control.665–667 | |
| p.60 | IIa | B1 | Atrioventricular node ablation combined with CRT should be considered in patients with severely symptomatic permanent AF and poor rate control despite medical therapy and at least one HFH to reduce symptoms, physical limitations, recurrent HFH, and death.672,673 | |
| p.60 | IIb | C | Intravenous amiodarone or digoxin may be considered in haemodynamically unstable patients with HFrEF and AF to stabilize the patient and achieve acute control of heart rate.668–671 | |
| p.60 | I | C | Cardioversion Urgent cardioversion is recommended in the setting of DHF in patients presenting with rapid ventricular rates and haemodynamic instability to restore sinus rhythm.669,671,692,695 | |
| p.60 | IIa | C | Atrial fibrillation catheter ablation Catheter ablation for AF should be considered in selectede patients with symptomatic AF and HFrEF to improve QoL and reduce the risk of HFH or death.674–676,678,681,682,684,696 | |
| p.62 | I | C | Coronary revascularization is recommended in patients with HF, obstructive CAD, and persistent angina, despite FMT for HF and antianginal drugs, to relieve symptoms.734,735 Revascularization for outcome improvement (HFrEF) | Recommendation Table 16 — Recommendations for revascularization in chronic coronary syndrome in patients with heart failure (see Evidence Table 82) |
| p.62 | IIa | B1 | If revascularization is planned after assessment by a Heart Team, CABG should be considered as the preferred revascularization strategy, in patients with LVEF ≤35% and multivessel CAD suitable for surgery, to improve long-term survival.180 | Recommendation Table 16 — Recommendations for revascularization in chronic coronary syndrome in patients with heart failure (see Evidence Table 82) |
| p.64 | I | B1 | Aortic stenosis Aortic valve intervention, SAVR or TAVI, is recommended in patients with severe aortic stenosis and HFc to improve symptoms and reduce the risk of death.758–765 Secondary mitral regurgitation | Recommendation Table 17 — Recommendations for valvular heart disease in patients with heart failure (see Evidence Tables 83 and 84) |
| p.64 | I | B1 | Mitral transcatheter edge-to-edge repair is recommended in haemodynamically stable, symptomatic patients with HFrEF and persistent severe secondary mitral regurgitation despite optimized FMT and CRT if indicated, who fulfil specific clinical and echocardiographic criteria,d in order to reduce the risk of HFH and improve QoL.750–753 | Recommendation Table 17 — Recommendations for valvular heart disease in patients with heart failure (see Evidence Tables 83 and 84) |
| p.64 | IIb | C | Mitral transcatheter edge-to-edge repair may be considered in selected symptomatic patients with HFrEF and persistent severe secondary mitral regurgitation despite optimized FMT and CRT if indicated (after excluding the option of LVAD or heart transplantation) who do not fulfil the clinical and echocardiographic criteria for outcome improvement,d in order to improve symptoms.766–769 | Recommendation Table 17 — Recommendations for valvular heart disease in patients with heart failure (see Evidence Tables 83 and 84) |
| p.65 | IIa | 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 QoL.315–317,819,820,825 | Recommendation Table 18 — Recommendations for obesity in patients with heart failure (see Evidence Tables 85 and 86) |
| p.65 | IIb | C | Bariatric surgery may be considered in obese patients with HF and a BMI ≥35 kg/m2 to reduce body weight when repetitive and structured lifestyle changes combined with weight-reducing medications do not result in maintained weight loss.823,824 | Recommendation Table 18 — Recommendations for obesity in patients with heart failure (see Evidence Tables 85 and 86) |
| p.67 | I | B1 | Intravenous iron supplementation is recommended in patients with symptomatic HFrEF and iron deficiency to alleviate HF symptoms and improve QoL.875–879 | Recommendation Table 19 — Recommendations for iron deficiency in patients with heart failure (see Evidence Tables 87 and 88) |
| p.67 | IIa | B1 | Intravenous iron supplementation should be considered in patients with symptomatic HFrEF and iron deficiency to reduce the risk of HFH.872–874,879,881,885,886,888 | Recommendation Table 19 — Recommendations for iron deficiency in patients with heart failure (see Evidence Tables 87 and 88) |
| p.68 | IIb | C | Adaptive servo-ventilation may be considered in patients with HFrEF and sleep-disordered breathing with predominant obstructive sleep apnoea to improve sleep quality, health-related QoL and symptoms.905 | Recommendation Table 20 — Recommendations for lung disease and sleep-disordered breathing (see Evidence Table 89) |
| p.68 | III | A | Adaptive servo-ventilation is not recommended in patients with HFrEF and sleep-disordered breathing with predominant central sleep apnoea because of an increased risk of CV and all-cause death.904 | Recommendation Table 20 — Recommendations for lung disease and sleep-disordered breathing (see Evidence Table 89) |
| p.68 | IIa | C | Assessment of anxiety, depression and frailty © ESC 2026 should be considered in patients with HF to support the development of personalized care plans and to identify factors that may contribute to adverse outcomes.909,914,915,920,923 HF, heart failure. aClass of recommendation. bLevel of evidence. | Recommendation Table 21 — Recommendations for anxiety, depression, and frailty (see Evidence Tables 90 and 91) |
| p.69 | IIa | C | Influenza and pneumococcal vaccination should be considered in patients with HF to reduce the risk of pneumonia complications, hospitalization, and death.931–934,936,953,954 | Recommendation Table 22 — Recommendations for other non-cardiovascular comorbidities (see Evidence Tables 92 and 93) |
| p.69 | III | B2 | NSAIDs and COX-2 inhibitors are not recommended in patients with HF as they increase the risk of HF worsening and HFH.942,946–948 | Recommendation Table 22 — Recommendations for other non-cardiovascular comorbidities (see Evidence Tables 92 and 93) |
| p.69 | I | B1 | © ESC 2026 A multidisciplinary HF management programme is recommended in patients with HF to reduce the risk of HFH and death.964–967 | Recommendation Table 23 — Recommendations for the multidisciplinary management of heart failure (see Evidence Tables 94–96) |
| p.69 | I | A | HF education and self-management strategies in patients with HF are recommended to reduce the risk of HFH or death.977 | Recommendation Table 23 — Recommendations for the multidisciplinary management of heart failure (see Evidence Tables 94–96) |
| p.69 | I | B2 | Multidisciplinary interventions to improve adherence, including assessment of health literacy and polypharmacy review, are recommended in patients with HF to reduce the risk of hospitalization and death.978–981 HF, heart failure; HFH, heart failure hospitalization. aClass of recommendation. bLevel of evidence. | Recommendation Table 23 — Recommendations for the multidisciplinary management of heart failure (see Evidence Tables 94–96) |
| p.72 | I | B1 | Personalized exercise training, in the context of multidisciplinary exercise-based cardiac rehabilitation, is recommended for all stable patients, unless there are specific contraindications, in order to improve exercise capacity and QoL, and reduce the risk of all-cause hospitalization.1021 | Recommendation Table 24 — Recommendations for exercise training and cardiac rehabilitation (see Evidence Tables 97–99) |
| p.72 | I | B2 | Personalized exercise training outside exercise-based cardiac rehabilitation is recommended for all stable patients on a long-term basis, unless there are specific contraindications, in order to improve exercise capacity and QoL, and reduce the risk of | Recommendation Table 24 — Recommendations for exercise training and cardiac rehabilitation (see Evidence Tables 97–99) |
| p.72 | I | B1 | all-cause hospitalization.1022 Cardiac rehabilitationc is recommended in patients with an LVAD to improve functional capacity and QoL.1005,1023 Cardiac rehabilitationc should be considered in patients with DHF, as soon as safely possible, to improve functional capacity and QoL.1002,1024– | Recommendation Table 24 — Recommendations for exercise training and cardiac rehabilitation (see Evidence Tables 97–99) |
| p.72 | IIa | B1 | © ESC 2026 Remote haemodynamic monitoring of PA pressure should be considered in symptomatic patients with HF, NYHA class III, and an HFH in the past 12 months in order to reduce the risk of HFH.1029,1043,1045 | Recommendation Table 25 — Recommendations for invasive and non-invasive telemonitoring (see Evidence Table 100) |
| p.72 | IIb | B1 | Non-invasive telemonitoring modalities may be considered for patients with HF in order to reduce the risk of HFH.1027,1029,1053 | Recommendation Table 25 — Recommendations for invasive and non-invasive telemonitoring (see Evidence Table 100) |
| p.74 | I | B1 | Proactive discussion regarding HF trajectory, goals of care, and advance care planning is recommended in patients with advanced HF to facilitate communication on end of life and QoL.627 | Recommendation Table 26 — Recommendations for longterm follow-up (see Evidence Tables 101 and 102) |
| p.74 | I | B2 | Access to an integrated HF palliative care multidisciplinary team is recommended for patients in an advanced HF stage to improve QoL and reduce symptom burden.1066–1068 HF, heart failure; QoL, quality of life. aClass of recommendation. bLevel of evidence. 12 Specific conditions | Recommendation Table 26 — Recommendations for longterm follow-up (see Evidence Tables 101 and 102) |
| p.74 | I | C | Pre-conception care and counselling is recommended for patients with HF to facilitate decision-making surrounding HF treatments, pregnancy, contraception, pre-implantation genetic screening, and assisted reproductive therapies. | Recommendation Table 27 — Recommendations for heart failure and pregnancy (see Evidence Tables 103–107) |
| p.74 | I | C | In pregnant women with HFrEF, it is recommended that non-selective beta-blockers are switched to beta1-selective blockers (metoprolol, bisoprolol) with close mother and foetus monitoring to reduce the risk of adverse foetal events and a lower birth weight.1072,1073 | |
| p.74 | III | C | ACE-Is, ARBs, ARNIs, MRAs, ivabradine, and SGLT2-Is are not recommended during pregnancy due to the risk of foetotocixity or teratogenicity.1074–1076 | |
| p.77 | I | A | Treatment with a TTR silencer (vutrisiran) or stabilizer (tafamidis or acoramidis) for patients with variant or wild-type transthyretin cardiac amyloidosis and NYHA classes I–III is recommended to reduce progression of symptoms and the risk of CV hospitalization and all-cause death.1082–1084 | Recommendation Table 28 — Recommendations for cardiac amyloidosis (see Evidence Tables 108–111) |