iCARDIO 2026 Guidelines on Heart Failure Management: Shaping Global Clinical Practice

Global Heart Failure Challenges and the Introduction of the iCARDIO 2026 Guidelines

Heart failure remains one of the leading global healthcare challenges, with high rates of morbidity, hospitalization, and mortality. Although guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC) have introduced significant pharmacological advancements, implementing these recommendations in low- and middle-income countries remains difficult due to disparities in healthcare infrastructure, medication affordability, and reimbursement policies.

To address these challenges, the 2026 iCARDIO Alliance Global Implementation Guidelines on Heart Failure were officially published in the Journal of Cardiac Failure. Developed by leading heart failure experts from more than 50 countries, the guideline establishes a flexible clinical framework that enables healthcare professionals to tailor treatment strategies according to local healthcare resources and patient needs.

Simplifying Heart Failure Classification and Defining HFimpEF

One of the most significant updates in the iCARDIO 2026 Guidelines is the simplification of heart failure classification to facilitate clinical decision-making, particularly in primary care settings.

Heart Failure with Reduced Ejection Fraction (HFrEF)

Patients with a left ventricular ejection fraction (LVEF) below 50% are classified as HFrEF. The guideline merges the previously recognized category of heart failure with mildly reduced ejection fraction (HFmrEF, LVEF 40-49%) into HFrEF, allowing these patients to immediately benefit from guideline-directed medical therapy (GDMT).

Heart Failure with Preserved Ejection Fraction (HFpEF)

HFpEF is defined as LVEF ≥50%, with diagnosis based on clinical symptoms and objective evidence of elevated left ventricular filling pressures through biomarkers such as BNP or NT-proBNP and echocardiographic findings.

Heart Failure with Improved Ejection Fraction (HFimpEF)

The guideline also standardizes the definition of HFimpEF, referring to patients who previously had an LVEF ≤40% and subsequently experienced an improvement of at least 10 percentage points, reaching an LVEF >40%.

Importantly, iCARDIO 2026 strongly emphasizes that GDMT should be continued indefinitely in HFimpEF patients, as discontinuation of therapy may result in recurrence of heart failure symptoms and adverse cardiac remodeling.

Four-Pillar GDMT for HFrEF and Resource-Based Adaptations

Expanded Use of Vericiguat, Intravenous Iron, and Emerging Therapies

In addition to the four-pillar GDMT strategy, iCARDIO 2026 introduces several important pharmacological updates.

Expanded Recommendation for Vericiguat

Based on pooled evidence from the VICTORIA and VICTOR studies, the guideline expands the use of Vericiguat, a soluble guanylate cyclase stimulator, for patients with HFrEF who have recently experienced worsening heart failure events.

The updated recommendation extends eligibility to patients with NT-proBNP levels below 6,000 pg/mL, compared with the previous threshold of 5,000 pg/mL.

Strong Recommendation for Intravenous Iron Therapy

Iron deficiency is highly prevalent among patients with heart failure and is associated with worse symptoms, reduced exercise capacity, and increased hospitalization risk, regardless of anemia status.

The iCARDIO 2026 Guidelines issue a strong recommendation for intravenous iron therapy using:

• Ferric Carboxymaltose
• Ferric Derisomaltose

in HFrEF patients with:

• Serum Ferritin <100 ng/mL
• Or Ferritin 100-299 ng/mL with TSAT <20%

Intravenous iron therapy has been shown to improve symptoms, functional status, and reduce heart failure-related hospitalizations.

GLP-1 Receptor Agonists for Obese HFpEF Patients

For patients with HFpEF and obesity, the guideline recommends considering GLP-1 receptor agonists such as:

• Semaglutide
• Tirzepatide

These agents can improve symptom burden, exercise capacity, and overall quality of life.

The Continued Role of Cardiac Glycosides

The guideline reaffirms the value of low-dose:

• Digoxin
• Digitoxin

with target serum concentrations of 0.5-0.9 ng/mL as cost-effective adjunctive therapies capable of reducing rehospitalization rates, particularly in regions with limited healthcare resources.

Discontinuing Low-Value Practices and Strengthening Vaccination Strategies

The iCARDIO 2026 Guidelines also identify several practices that should be avoided.

Healthcare professionals are advised to:

• Avoid discontinuing GDMT in patients with HFimpEF despite apparent recovery of LVEF.
• Avoid prescribing statins solely for heart failure without another established indication.
• Avoid routine oral anticoagulation in heart failure patients unless indicated by conditions such as atrial fibrillation.
• Avoid using diltiazem or verapamil in HFrEF because of their negative inotropic effects.

To reduce the risk of acute decompensation, the guideline further recommends comprehensive vaccination strategies, including:

• Annual Influenza Vaccine
• Pneumococcal Vaccine
• COVID-19 Vaccine
• Herpes Zoster Vaccine
• Respiratory Syncytial Virus (RSV) Vaccine

VINPHACO’s Commitment to Delivering High-Quality Cardiovascular Therapies

As a trusted pharmaceutical manufacturer and exporter in Vietnam, VINPHACO (Vinh Phuc Pharmaceutical Joint Stock Company) continuously integrates the latest international medical recommendations into its product development strategy.

To support the evolving needs of cardiovascular care, VINPHACO remains committed to optimizing the manufacturing and supply of internationally compliant cardiovascular medicines, including antihypertensive therapies, heart failure treatments, and both oral and intravenous iron formulations. Through quality-focused production and global distribution capabilities, VINPHACO contributes to improving treatment outcomes for patients worldwide.