Heart failure therapy (FMT/GDMT)

ACC/AHA/HFSA 2022 (Table 4): HFrEF ≤40%, HFmrEF 41–49%, HFpEF ≥50%, plus HFimpEF (previous LVEF ≤40% and a follow-up LVEF >40%). For HFimpEF it says to continue GDMT (Class 1, B-R).

ESC 2026 (Section 3.3.1) “has eliminated the phenotype of HFmrEF”. It keeps two phenotypes: HFrEF, LVEF <50%, and HFpEF, LVEF ≥50% with objective evidence of structural or functional abnormality. It has no separate improved-EF phenotype. Improved LVEF means a rise of at least 10 points to above 40%. These patients continue FMT (I, C).

So LVEF 41–49% is HFmrEF under ACC/AHA (beta-blocker, ARNI/ACEi/ARB and MRA 2b; SGLT2 inhibitor 2a) and HFrEF under ESC (all four FMT classes Class I). The ESC adds that no large RCT has tested beta-blockers or ACE-I/ARNI/ARB exclusively at 41–49%. The tool shows each society's class under its own category.

Some ESC recommendations carry their own LVEF limit: ivabradine ≤35%, cardiac glycoside and hydralazine–ISDN ≤40%, vericiguat <45%, semaglutide/tirzepatide ≥45%. If you type an LVEF, the tool applies these limits; without one, the badge shows the class with its limit.

US status (Oct 2026): no ACC/AHA/HFSA HF guideline or focused update newer than 2022 was found. The 2026 Second Universal Definition of HF (AHA/ACC/ESC/WHF) groups HF as reduced, preserved and improved EF without fixed cut-offs. It notes that an LVEF <50% is unlikely to be normal, but it gives no classes of recommendation. The ACC HFrEF (2024) and HFpEF (2026) pathways are consensus documents. The 2022 classes therefore remain the US reference here.

ESC 2026 (Figure 3): GDMT includes foundational medical therapy (FMT) and additional medical therapy (AMT). FMT is therapy with a Class I recommendation for the general HF population and convincing evidence of lower morbidity or mortality. For HFrEF that means beta-blocker, ACE-I/ARNI/ARB, MRA and SGLT2 inhibitor; for HFpEF, MRA and SGLT2 inhibitor. Everything else is AMT: IIa/IIb recommendations, Class I for symptoms only (for example diuretics, IV iron for symptoms), or Class I in specific subsets.

ACC/AHA 2022 uses “guideline-directed medical therapy (GDMT)” for the recommended HFrEF drugs.

ACC/AHA: 1 = recommended · 2a = reasonable · 2b = may be considered · 3 = no benefit or harm. LOE A, B-R (randomized), B-NR, C-LD, C-EO.

ESC 2026: I = recommended · IIa = should be considered · IIb = may be considered · III = not recommended. For therapy, the 2026 guideline splits level B into B1 and B2.

• Titrate to the target doses used in the trials, or the highest tolerated dose (ACC/AHA 1, A; ESC Table 11).
• Adjust doses as often as every 1–2 weeks, guided by symptoms, vital signs and labs (ACC/AHA 2a, C-EO; ESC “at least every 1–2 weeks”, I, C).
• The ESC accepts a creatinine rise of <50% above baseline after starting RAAS inhibitors, MRAs or SGLT2 inhibitors, as long as eGFR stays >15. Asymptomatic or tolerable hypotension should not lead to down-titration or stopping FMT.
• In-hospital rules: see the In hospital (DHF) section above.

Trial/ACC/AHA definition: ferritin <100 µg/L, or 100–299 µg/L with TSAT <20%.

ESC 2026: the Task Force supports TSAT <20%, because the ferritin-based definition includes people who are probably not iron-deficient.

• The phenotype selector now uses LVEF bands (≤40, 41–49, ≥50, improved) and shows how each society classifies the band. ESC 2026 folds LVEF 41–49% into HFrEF (<50%); ACC/AHA 2022 keeps HFmrEF.
• New terms: ESC foundational medical therapy (FMT) and ACC/AHA GDMT, each used where it applies.
• Typing an LVEF picks the band and applies the class-specific ESC LVEF limits (vericiguat <45%, semaglutide/tirzepatide ≥45%, glycoside and H-ISDN ≤40%, ivabradine ≤35%).
• New In hospital (DHF) section: when to start or continue each class, uptitration cadence and a pre-discharge checklist.
• Printed ESC citation added (Eur Heart J 2026;47:5346–5457). No newer US guideline exists, so ACC/AHA 2022 stays.
• Removed statements this review could not re-verify.