ESC's new heart failure guideline recommends semaglutide and tirzepatide for HFpEF with obesity

The European Society of Cardiology used its 2026 Congress in Munich to release updated heart failure guidelines that recommend Novo Nordisk's GLP-1 agonist semaglutide and Eli Lilly's dual GIP/GLP-1 agonist tirzepatide for patients who have heart failure with preserved ejection fraction (HFpEF) along with obesity ^[1].

The recommendation is part of a broader rewrite of how European cardiologists classify and treat heart failure. The guidelines also changed how heart failure is sorted by left ventricular ejection fraction (LVEF), the share of blood the heart's main pumping chamber pushes out with each beat. The category of heart failure with mildly reduced ejection fraction has been removed, and those patients split between the two remaining groups ^[1]. As reported from the Congress, patients are now classified as having either heart failure with reduced ejection fraction (HFrEF), with an LVEF of 50% or less, or HFpEF, with an LVEF above 50% ^[1].

On drug therapy, the update also backs mineralocorticoid receptor antagonists — the class that includes Bayer's Kerendia (finerenone) — in chronic heart failure regardless of LVEF ^[1].

What the source does and does not say

The published report of the Munich announcement names semaglutide and tirzepatide and the patient group they are recommended for, but it does not spell out the strength of the recommendation, the specific trials cited, dosing, or which brand versions of each molecule the guideline writers had in mind ^[1]. Semaglutide is sold as Ozempic, Wegovy and Rybelsus; tirzepatide is sold as Mounjaro and Zepbound. Which of those products, if any, carry an HFpEF-related indication in the United States is not addressed in the available source, so any claim of a formal split between European guidance and US labeling cannot be confirmed from this reporting.

Separately, the same Congress saw four major cardiovascular organizations — the ESC, the American College of Cardiology, the American Heart Association and the World Heart Federation — propose a new universal definition of myocardial infarction (MI), or heart attack ^[1]. The old numbering system, types 1 through 5, was criticized as overly complex and confusing, and "not always easy to apply in clinical practice, leading to inconsistencies in diagnosis and treatment," said ESC Chair Prof Nicholas Mills of the University of Edinburgh ^[1].

The replacement uses three categories: primary MI, covering spontaneous acute coronary problems such as atherothrombosis, vasospasm and spontaneous coronary artery dissection (SCAD); secondary MI, where another acute illness such as severe anemia, respiratory failure or sudden blood loss is the cause; and procedure-related MI occurring within 30 days of a cardiac intervention ^[1]. SCAD is up to nine times more common in women than men, and the new scheme introduces lower, sex-specific troponin thresholds and encourages precise coronary imaging for heart attacks not caused by clots ^[1].

Why it matters for patients

HFpEF is a form of heart failure in which the heart muscle stiffens and fills poorly even though its pumping fraction looks normal, and it has historically had few proven drug treatments. A guideline recommendation is not the same as a regulatory approval, but guidelines shape what cardiologists offer, what hospitals stock, and what insurers are asked to cover. For US patients with both HFpEF and obesity, a European recommendation may be raised in conversations with clinicians even where domestic prescribing information has not changed.

The reclassification of ejection fraction categories matters too. People previously told they had "mildly reduced" ejection fraction may find themselves described differently in European practice, which can change which treatment pathway applies to them ^[1].

The MI redefinition is aimed partly at women whose heart attacks are underdiagnosed and undertreated. The framework's authors say it should improve diagnosis and management, help patients understand their own condition, and open new research avenues ^[1]. "With the new approach, we can now talk with patients about the cause of their MI so that they can understand their condition and recognise why the next steps, such as further tests and treatments, are needed," said ACC/AHA chair Prof Kristin Newby ^[1].

What happens next

The guidelines and the MI classification were unveiled at the ESC Congress in Munich, with the report published 31 August 2026 ^[1]. Because the ACC, AHA and World Heart Federation co-authored the MI definition, US adoption of that piece is likely, though no implementation dates appear in the source ^[1]. Whether US regulators act on the HFpEF recommendation, and on what timeline, is not yet known from the available reporting.