The European Society of Cardiology published new heart failure guidelines on August 28, 2026 in the European Heart Journal, and two changes stand out: weight-loss drugs semaglutide and tirzepatide now carry a formal recommendation for heart failure patients with obesity, and the “mildly reduced ejection fraction” category has been deleted. The guidelines were released in Munich, Germany, ahead of their presentation at ESC Congress 2026.
Key takeaways
- Heart failure is now sorted into two groups instead of three: reduced ejection fraction (under 50%) and preserved ejection fraction (50% or more).
- Semaglutide or tirzepatide get a Class IIa recommendation for patients with preserved ejection fraction and obesity.
- Mineralocorticoid receptor antagonists move up to Class I for chronic heart failure no matter what the ejection fraction is.
What happened
Ejection fraction measures how much blood the left ventricle pushes out with each beat. The old guidelines split heart failure into three phenotypes by that number. The 2026 guidelines remove the middle one, mildly reduced ejection fraction, which covered an LVEF of 41 to 49%. What is left is heart failure with reduced ejection fraction, now defined as an LVEF under 50%, and heart failure with preserved ejection fraction, an LVEF of 50% or more.
Task Force Chair Associate Professor Marianna Adamo of the University and Civil Hospital of Brescia, Italy explained the reasoning in the ESC release: those middle patients “share similar pathophysiology and benefit from similar treatments as those with reduced LVEF. Thus, we decided to simplify the classification.”
On drugs, the ESC lists two changes based on new evidence. Mineralocorticoid receptor antagonists get a Class I recommendation in chronic heart failure independent of ejection fraction, meaning the treatment is recommended. Semaglutide or tirzepatide get a Class IIa recommendation in patients with preserved ejection fraction and obesity, meaning it should be considered.
The language changed too. The word “acute” is gone, replaced by “decompensated,” because, as Adamo put it, “in some patients, heart failure does not suddenly get worse but rather, heart function gradually declines to the point where the heart can no longer compensate for its defects.” The guidelines also drop the catch-all phrase “guideline-directed medical therapy” in favor of three named tiers: foundational medical therapy, additional medical therapy, and guideline-directed interventional therapy.
Heart failure affects an estimated 1% to 3% of adults, according to the ESC, and fewer than 60% of people diagnosed with it are alive five years later.
Dr. Kumar’s take
The GLP-1 recommendation is the bigger story, and not for the reason most coverage will give. Obesity has sat in cardiology documents for decades as a risk factor, something you counsel about. Putting semaglutide and tirzepatide into the treatment recommendations for preserved ejection fraction moves body weight into the column of things you treat with a drug in order to treat the heart. That is a different claim about what obesity is doing in these patients.
Class IIa is not a mandate. It means “should be considered,” which is the guideline system’s way of saying the evidence is good but not settled. The practical obstacles are real. These are expensive drugs, insurance coverage for a cardiac indication is uneven, and the benefit lasts only as long as you keep taking them. In older patients with heart failure, the loss of muscle along with fat that comes with rapid weight loss deserves more attention than a Class IIa line conveys, because muscle mass tracks with function and survival in this population. GLP-1 drugs keep collecting evidence across organ systems, including better survival signals in breast cancer.
The deleted middle category will get less attention. Everyone who used to fall in that 41 to 49% band is now simply in the reduced group, which means the fuller drug regimen used for low ejection fraction now applies to them by default rather than by argument. I read that as a large, low-profile expansion of who gets treated aggressively, justified on the reasonable grounds that those patients respond like the sicker group. It also removes a diagnostic hedge that let clinicians wait and watch.
To me the mineralocorticoid receptor antagonist upgrade to Class I regardless of ejection fraction is the least flashy change and possibly the most useful. Spironolactone and eplerenone are cheap, old, and generic.
What it means for you
If you or a family member has heart failure, the ejection fraction number on the last echo report may now put you in a different category than it did last year, with a different drug list attached. That is worth a conversation at the next cardiology visit, not a phone call tonight.
If your ejection fraction is 50% or above and you carry excess weight, ask whether a GLP-1 drug fits your situation, and ask about cost, how long you would stay on it, and how to protect muscle while losing weight.
Guidelines describe populations; your cardiologist knows your kidney function, blood pressure, and history. Living with heart failure also carries a real mental health load, and how depression is treated in heart failure patients matters alongside the cardiac drugs.