ESC Congress opens: new heart failure guidelines and a rewritten definition of myocardial infarction

First guidelines entry on the site, and a heavy day: ESC Congress 2026 opened in Munich this morning. The two ESC items below were published online today; the MI definition is formally presented at Congress on 30 August. Expect more through 31 August.

Checked and found nothing new in the window: SFAR, SRLF, SPILF (the most recent SFAR formalised expert recommendations date from April 2026), ESAIC, ESICM, ESPEN, SCCM, EACTS, STS, IACTS.

1. 2026 ESC Guidelines for the management of heart failure

Society · Published: European Society of Cardiology, European Heart Journal, 28 August 2026 — genuinely new, today Køber et al.

Access note: published too recently to be indexed, so the detail below comes from ESC’s own release and press coverage, not from the guideline text. Flagged as secondary sourcing.

The headline change is classification collapsing from three phenotypes to two:

• HFrEF — LVEF <50%
• HFpEF — LVEF ≥50%

The mildly-reduced category (LVEF 41–49%) is eliminated, on the reasoning that those patients “share similar pathophysiology and benefit from similar treatments as those with reduced LVEF.” A stage-based classification is introduced alongside, weighted toward prevention, early recognition and timely intervention.

Terminology also changes: “acute” becomes “decompensated”, to convey that decline is usually gradual rather than sudden. Guideline-directed medical therapy is replaced by three named tiers — foundational medical therapy (strongest evidence, all patients), additional medical therapy (specific subsets), and guideline-directed interventional therapy (devices and procedures).

Recommendations reported as changed:

• Class I — mineralocorticoid receptor antagonists in chronic heart failure, independent of LVEF
• Class IIa — semaglutide or tirzepatide for HFpEF with obesity
• Upgrades for digoxin/digitoxin, mechanical circulatory support, and transcatheter mitral valve repair in specific situations
• Non-steroidal MRAs and incretin-based therapies enter for mildly-reduced and preserved EF; rapid GDMT optimisation strategies in acute HF are validated

Interpretation. Deleting HFmrEF is the consequential move. That category was always a compromise born of trials that enrolled by ejection fraction cutoffs, and in practice it left a band of patients whose treatment depended on which side of an arbitrary line an echo landed on. Folding 41–49% into HFrEF means those patients now inherit the full foundational regimen by default. The incretin recommendation is the other notable one: obesity moves from comorbidity to treatment target in HFpEF. For perioperative and critical care, the practical consequence is that more patients will arrive on four-drug foundational therapy, with the attendant intraoperative hypotension and renal questions.

Guideline page · DOI 10.1093/eurheartj/ehag100

2. Fifth Universal Definition of Myocardial Infarction (2026)

Society · Published: ESC, ACC, AHA and the World Heart Federation jointly; European Heart Journal, online 28 August 2026, presented at Congress 30 August — genuinely new, today Mills et al.

Access note: as above — detail from the societies’ release and press coverage, not the document itself.

The numerical MI types are gone. Types 1 through 5 are replaced by three clinical categories:

1. Primary MI — spontaneous, from an acute coronary artery problem: atherosclerotic plaque rupture, spontaneous coronary artery dissection, spasm, or thrombosis
2. Secondary MI — from oxygen supply–demand imbalance driven by another condition, such as extreme blood pressure change or rapid heart rate
3. Procedure-related MI — within 30 days of a cardiac intervention such as stenting or bypass surgery

Professor Nicholas Mills, ESC chair of the writing group: “The previous universal definition used a numerical system to categorize the different types of MI but this was not always easy to apply in clinical practice, leading to inconsistences in diagnosis and treatment.” The new categories are aligned with how clinical evaluation actually proceeds, and coordinated with ICD-11 coding for global health monitoring.

Interpretation. This one reaches well beyond cardiology, and it lands directly in cardiothoracic and perioperative practice. “Type 2 MI” and “type 4a/4c” were notoriously inconsistently applied — the terminology rarely survived contact with a ward round, let alone a conversation with a patient. Postoperative myocardial injury after non-cardiac surgery, and myocardial damage after cardiac surgery, both sit squarely in the new secondary and procedure-related categories — so this changes how perioperative troponin rises get labelled, coded and studied. Note the 30-day window on procedure-related MI: that is a wider net than many surgical follow-up protocols currently cast. Worth watching whether the ICD-11 alignment makes registry and trial endpoints more comparable, which was arguably the deepest problem with the numerical scheme.

DOI 10.1093/eurheartj/ehag101

3. PUMA guidelines for tracheal extubation

Society · Published: Project for Universal Management of Airways, Anaesthesia, 26 August 2026 — genuinely new, 2 days old Ellard, Higgs, Cooper, Hagberg, Baker, Greif, Kovacs, Law, Myatra, O’Sullivan, Rosenblatt et al.

An international, multidisciplinary working group reviewed existing airway guidelines and the published literature, then ran a structured expert-consensus process with an international advisory group of airway operators, airway assistants and human factors experts. Discrepancies between the two processes were analysed and reconciled. Recommendations are graded on the American Heart Association classification system.

The scope is tracheal extubation, but the principles extend to all discontinuation of airway management — removing a supraglottic airway, ceasing facemask support, tracheostomy removal — and to conversion between airway “lifelines”.

Substance:

• Risk evaluation covers the risk of hypoxaemia, pulmonary aspiration, and harm from airway stimulation, assessed against the patient’s baseline risk and any change since intubation.
• Team and situation risk factors are weighed alongside patient factors when forming the extubation strategy.
• Planned extubation is always elective — which maximises control over timing, environment and available resources. Deferring extubation is recommended where that meaningfully decreases risk.
• When substituting one airway lifeline for another, “conversion procedures” — those with a continuous guide maintaining or enabling rapid restoration of alveolar ventilation — are safer and preferred over “replacement procedures”, particularly where the airway is regarded as at risk.

Interpretation. The most quotable line is that planned extubation is always elective. Extubation has long been the neglected half of airway management — enormous guideline attention on getting the tube in, comparatively little on taking it out, despite adverse events clustering there. Framing it as an elective act with a deferral option is a direct challenge to the pressure to extubate on schedule. The conversion-over-replacement principle codifies what careful practitioners already do with airway exchange catheters, and gives it a name and a grade, which is what makes it teachable and auditable. Note the authorship — Higgs, Cooper, Hagberg, Law, Myatra, Greif — this is the international difficult-airway establishment, so it will propagate into national guidance quickly.

DOI 10.1111/anae.70365 · PMID 42644413

4. ATS guideline — noninvasive respiratory support in acute respiratory failure

Society · Published: American Thoracic Society, AJRCCM — first published 29 June 2026, so ~2 months old, not new. It appeared on the aggregator’s 27 August listing; the listing date is not the publication date. Goel, Ferreyro, Pitre, Lewis et al.

The first guideline to address the different noninvasive respiratory support strategies comprehensively across the spectrum of acute respiratory failure. A multidisciplinary panel used GRADE across four PICO questions, informed by several systematic reviews and network meta-analyses.

• Acute hypoxaemic respiratory failure: strong recommendation for HFNC; conditional for NIV or CPAP — with close monitoring for the need to escalate. Based primarily on effects on intubation.
• Acute hypercapnic respiratory failure: strong recommendation for NIV, to reduce mortality and need for invasive ventilation. Conditional for HFNC only in less severe hypercapnia with mild acidaemia (e.g. pH > 7.25), provided close monitoring and prompt escalation to NIV are available.
• Preoxygenation before intubation: strong recommendation for HFNC or NIV to prevent peri-intubation hypoxaemia.
• Post-extubation: risk-based — HFNC for low-risk patients, NIV for high-risk, to reduce reintubation.

Interpretation. The strong-for-HFNC-in-hypoxaemia recommendation is the one that will draw argument, given FLORALI’s contested subgroup and the mixed RECOVERY-RS and HiFLo-Covid picture — the panel has come down harder than the trial base alone might support, resting on intubation rather than mortality. The hypercapnia recommendations are less controversial and more precisely drawn; the pH > 7.25 boundary for HFNC is the practical number to remember. Note also that this pairs directly with the PUMA guideline above: post-extubation support strategy and extubation risk assessment are the same clinical decision viewed from two sides, and the two documents arrived within two months of each other from different societies.

DOI 10.1093/ajrccm/aamag302 · PMID 42371750