ESC Munich 2026: the results that change practice

Heart failure, MI definition, PE thrombolysis, prasugrel

Evidence · week of 2026-08-31 · Cardiology, Internal Medicine, Emergency Medicine · 8 min read · published September 7, 2026

ESC Munich 2026 delivered practice-changing evidence: simplified HF phenotypes, a new MI classification, catheter-directed thrombolysis for PE, and prasugrel's bleeding advantage over ticagrelor.

Hibbert Medical · Week of 31 August 2026 · Evidence briefing

> At a glance > What we know — ESC Congress 2026 in Munich (28–31 August) saw the 2026 ESC heart failure guideline, which simplifies phenotypes to two categories (HFrEF <50%, HFpEF ≥50%) and introduces foundational/additional/interventional therapy nomenclature [1]; the Fifth Universal Definition of Myocardial Infarction, which replaces numerical MI types with primary, secondary and procedure-related categories [2]; and the PRAGUE-26 trial, showing catheter-directed thrombolysis reduced death, recurrence or cardiorespiratory collapse to 0.7% versus 6.8% with anticoagulation alone in intermediate–high-risk pulmonary embolism (RR 0.10, 95% CI 0.02–0.44, p<0.001) [3,4]. > What we don't know yet — Whether PRAGUE-26's seven-day benefit persists beyond the acute phase; whether the prasugrel-default policy's bleeding advantage translates into long-term net clinical benefit; whether PVI-SHAM-AF's null quality-of-life result at six months will change with extended observation; whether AMUNDSEN's LDL-C lowering will produce clinical benefit beyond one year [3,4,5,6,7]. > What changes Monday — Clinicians managing heart failure should adopt the two-phenotype classification; those coding MI should use primary/secondary/procedure-related categories; centres treating intermediate–high-risk PE should consider catheter-directed thrombolysis; and prasugrel may be preferred over ticagrelor in acute coronary syndrome patients undergoing percutaneous coronary intervention where both agents are available [1,2,3,6].

What happened

The 2026 ESC Guidelines for the management of heart failure were published in the European Heart Journal and presented at ESC Congress 2026 on 28 August [1]. The Fifth Universal Definition of Myocardial Infarction was presented at ESC Congress 2026 on 30 August [2]. SWITCH SWEDEHEART trial results were presented on 29 August and published simultaneously in the New England Journal of Medicine [6,8]. AMUNDSEN trial results were presented on 29 August and published in JAMA [7]. The China Rural Hypertension Control Program (CRHCP) dementia results were presented on 30 August [9]. PRAGUE-26 trial results were presented on 31 August and published simultaneously in the New England Journal of Medicine [3,4]. PVI-SHAM-AF trial results were published in The Lancet in 2026 [5].

What the evidence actually shows

2026 ESC heart failure guideline: staging, phenotypes and therapy nomenclature

The 2026 ESC heart failure guideline adopts a four-stage framework (stages A–D), removes the HFmrEF phenotype and now describes only two: HFrEF (LVEF <50%) and HFpEF (LVEF ≥50%) [1]. New class I recommendations include mineralocorticoid receptor antagonists in chronic heart failure independent of LVEF, and class IIa recommendations include semaglutide or tirzepatide in patients with preserved LVEF and body mass index 30 or higher [1]. Practice-changing: the staging framework, two-phenotype classification and foundational therapy nomenclature represent a conceptual reset requiring re-education of multidisciplinary teams [1].

Fifth Universal Definition of Myocardial Infarction: primary, secondary and procedure-related categories

The Fifth Universal Definition recategorises MI into three types: primary MI (spontaneous presentations due to primary acute coronary pathology), secondary MI (resulting from myocardial oxygen supply–demand imbalance caused by another acute condition), and procedure-related MI (occurring within 30 days of a cardiac procedure) [2]. Practice-informing: the shift from numerical types to clinically descriptive categories aligns classification with the contexts clinicians already think in [2].

PRAGUE-26: catheter-directed thrombolysis in intermediate–high-risk pulmonary embolism

PRAGUE-26 enrolled 558 patients with acute intermediate–high-risk pulmonary embolism, median age 64 years, 41% women, and randomised them 1:1 to catheter-directed thrombolysis with alteplase plus anticoagulation or anticoagulation alone [3,4]. The primary endpoint occurred in 2 patients (0.7%) in the catheter-directed thrombolysis group and 19 patients (6.8%) in the anticoagulation-alone group (RR 0.10, 95% CI 0.02–0.44, p<0.001), driven primarily by lower cardiorespiratory decompensation or collapse [3,4]. Bleeding events within seven days occurred in 4.6% of the catheter-directed thrombolysis group versus 5.0% of the anticoagulation-alone group (p=0.846), with two cases of intracranial haemorrhage in the catheter-directed thrombolysis group and none in the anticoagulation-alone group [3,4]. Practice-changing: PRAGUE-26 provides robust randomised evidence that catheter-directed thrombolysis can reduce early clinical deterioration in intermediate–high-risk pulmonary embolism with an acceptable bleeding profile [3,4].

SWITCH SWEDEHEART: prasugrel versus ticagrelor in acute coronary syndromes

SWITCH SWEDEHEART enrolled 17,095 consecutive adults with acute coronary syndromes undergoing percutaneous coronary intervention [6,8]. The primary endpoint of death, myocardial infarction or stroke at one year occurred in 11.1% of patients under the prasugrel policy and 11.8% under the ticagrelor policy (adjusted OR 0.90, 95% CI 0.77–1.06) [6,8]. Major bleeding at one year was significantly lower with the prasugrel policy (4.2% vs 4.4%, OR 0.80, 95% CI 0.64–0.99) [6,8]. Practice-informing: in the largest randomised comparison to date, prasugrel offered comparable protection against major cardiovascular events with a signal toward less bleeding [6,8].

CRHCP: intensive blood pressure control and dementia

CRHCP randomised 326 rural Chinese villages 1:1 to a non-physician community healthcare provider-led intensive blood pressure intervention (target <130/80 mmHg) versus usual care, enrolling 33,995 participants aged 40 years or older [9]. After seven years, the incidence of all-cause dementia was 8.85% in the intervention group and 10.55% in the usual-care group (adjusted risk ratio 0.85, 95% CI 0.78–0.91, p<0.001), a 15% relative risk reduction [9]. Practice-informing: a scalable, community-delivered intensive blood pressure intervention reduced dementia risk over seven years without increasing serious adverse events [9].

PVI-SHAM-AF: catheter ablation versus sham procedure for atrial fibrillation

PVI-SHAM-AF randomised 262 patients with symptomatic paroxysmal or persistent atrial fibrillation in a 2:1 ratio to catheter ablation versus a sham procedure [5]. The primary endpoint was the between-group difference in change from baseline to six months in the Atrial Fibrillation Effect on Quality-of-life Questionnaire (AFEQT) summary score [5]. The Hodges–Lehmann estimate of the between-group difference in change was 2.6 points (95% CI −2.7 to 8.0; p=0.36), indicating no statistically significant superiority of catheter ablation over the sham procedure [5]. Not practice-changing: catheter ablation did not show quality-of-life superiority over sham at six months, and longer follow-up is ongoing [5].

AMUNDSEN: immediate evolocumab after acute myocardial infarction

AMUNDSEN randomised patients with acute myocardial infarction undergoing percutaneous coronary intervention to first-line evolocumab combined with high-intensity lipid-lowering therapy or to standard care [7]. Evolocumab produced rapid and sustained LDL-C reduction, with more than 80% of patients reaching the guideline-recommended target at one year [7]. No clinical benefit was detected during the first year of follow-up, arguing against clinically meaningful acute pleiotropic effects of PCSK9 inhibition on top of standard care [7]. Not practice-changing: evolocumab lowers LDL-C quickly after MI but has not yet been shown to improve one-year clinical outcomes [7].

How clinicians are reacting

  • JAMA Editors' Summary, 4 September 2026 — The AMUNDSEN trial showed early evolocumab achieved significantly higher LDL goal attainment (82% vs 40% at 12 months), but there was no significant difference in the primary clinical endpoint of all-cause death or unplanned cardiovascular hospitalisation at 12 months [10].
  • This Week in Cardiology, 4 September 2026 — The CMR Guide trial found that in patients with LVEF 36–50% and significant scar, primary prevention ICDs did not significantly reduce sudden cardiac death or ventricular arrhythmias compared to implantable loop recorders, with event rates far lower than historical trials [11].
  • EMCrit PulmCrit, 31 August 2026 — PRAGUE-26 is overall pretty similar to HI-PEITHO; most people are already dug in on their positions on intermediate-high risk pulmonary embolism [12].
  • Medical Xpress, 31 August 2026 — Catheter ablation for atrial fibrillation did not significantly improve AF-related quality of life compared with a sham procedure, despite reducing AF recurrence [13].
  • Medical Xpress, 31 August 2026 — Immediate evolocumab after a heart attack significantly improved LDL-cholesterol goal achievement, but an early reduction in all-cause death or unplanned cardiovascular hospitalisation was not observed compared with standard care [14].

What this changes in practice, and what it doesn't

Clinicians managing heart failure should adopt the new two-phenotype classification (HFrEF <50%, HFpEF ≥50%) and foundational therapy framework [1]. Mineralocorticoid receptor antagonists should be considered in all symptomatic chronic heart failure patients independent of LVEF unless contraindicated, and semaglutide or tirzepatide should be considered in HFpEF patients with body mass index 30 or higher [1]. Clinicians coding myocardial infarction should begin using the new primary/secondary/procedure-related categories rather than numerical MI types [2]. Centres treating intermediate–high-risk pulmonary embolism should consider catheter-directed thrombolysis as a standard option, though intracranial haemorrhage risk requires careful patient selection [3,4]. Prasugrel may be preferred over ticagrelor in acute coronary syndrome patients undergoing percutaneous coronary intervention where both agents are available [6,8]. Catheter ablation for atrial fibrillation did not demonstrate quality-of-life superiority over sham at six months; longer follow-up may clarify its role [5].

For learners

Question 1 A 72-year-old woman with chronic heart failure and left ventricular ejection fraction of 46% is reviewed in clinic. According to the 2026 ESC heart failure guidelines, which statement is correct?

A. She has heart failure with mildly reduced ejection fraction (HFmrEF) and should not receive a mineralocorticoid receptor antagonist B. She has heart failure with reduced ejection fraction (HFrEF) and should be considered for a mineralocorticoid receptor antagonist C. She has heart failure with preserved ejection fraction (HFpEF) and should be considered for a mineralocorticoid receptor antagonist D. She has heart failure with preserved ejection fraction (HFpEF) and should not receive a mineralocorticoid receptor antagonist

Answer: B The 2026 ESC guidelines define HFrEF as LVEF <50%, removing the HFmrEF category; LVEF 46% is HFrEF, and the guidelines recommend mineralocorticoid receptor antagonists in chronic heart failure independent of LVEF (class I) [1].

Question 2 A 58-year-old man presents with chest pain and elevated cardiac troponin. He is found to have severe sepsis with hypotension requiring vasopressor support. Coronary angiography shows no obstructive coronary artery disease. According to the Fifth Universal Definition of Myocardial Infarction (2026), how should this event be classified?

A. Primary myocardial infarction B. Secondary myocardial infarction C. Procedure-related myocardial infarction D. Not a myocardial infarction

Answer: B Secondary MI results from myocardial oxygen supply–demand imbalance caused by another acute condition; sepsis-induced hypotension causing myocardial injury in the absence of primary coronary pathology is classified as secondary MI [2].

Question 3 A 65-year-old man with intermediate–high-risk pulmonary embolism is being considered for catheter-directed thrombolysis. Based on the PRAGUE-26 trial, which statement is most accurate?

A. Catheter-directed thrombolysis reduces the risk of death, recurrence or cardiorespiratory collapse at seven days compared with anticoagulation alone, with no increase in major bleeding B. Catheter-directed thrombolysis reduces the risk of death, recurrence or cardiorespiratory collapse at seven days compared with anticoagulation alone, but with a significantly higher risk of major bleeding C. Catheter-directed thrombolysis does not reduce the risk of death, recurrence or cardiorespiratory collapse at seven days compared with anticoagulation alone D. Catheter-directed thrombolysis reduces the risk of death at seven days compared with anticoagulation alone, but with a significantly higher risk of intracranial haemorrhage

Answer: A PRAGUE-26 showed that catheter-directed thrombolysis reduced the primary composite endpoint from 6.8% to 0.7% (RR 0.10, 95% CI 0.02–0.44, p<0.001) with no apparent difference in overall bleeding events (4.6% vs 5.0%, p=0.846), though two intracranial haemorrhages occurred in the intervention group and none in the control group [3,4].

References

  1. Major changes made to the ESC Guidelines on heart failure. escardio.org. press-release. https://www.escardio.org/news/press/press-releases/major-changes-made-to-the-esc-guidelines-on-heart-failure/
  2. New global definition of myocardial infarction aims to improve diagnosis, treatment and patient understanding. escardio.org. press-release. https://www.escardio.org/news/press/press-releases/new-global-definition-of-myocardial-infarction-aims-to-improve-diagnosis-treatment-and-patient-understanding/
  3. Positive news for the treatment of pulmonary embolism. escardio.org. press-release. https://www.escardio.org/news/press/press-releases/positive-news-for-the-treatment-of-pulmonary-embolism
  4. Kroupa J, Radvan M, Mrozek J, et al. Catheter-Directed Thrombolysis in Intermediate-High-Risk Pulmonary Embolism. The New England journal of medicine 2026. doi:10.1056/NEJMoa2608012. PMID: 42678032. https://pubmed.ncbi.nlm.nih.gov/42678032/
  5. Wachter R, Haag P, Uhe T, et al. Catheter ablation for symptomatic atrial fibrillation (PVI-SHAM-AF): a randomised, double-blind, sham-controlled, multicentre trial. Lancet (London, England) 2026. doi:10.1016/S0140-6736(26)01558-8. PMID: 42669307. https://pubmed.ncbi.nlm.nih.gov/42669307/
  6. Results from SWITCH SWEDEHEART favour prasugrel over ticagrelor after coronary stenting. escardio.org. press-release. https://www.escardio.org/news/press/press-releases/results-from-switch-swedeheart-favour-prasugrel-over-ticagrelor-after-coronary-stenting/
  7. LDL Cholesterol Lowering With Evolocumab Before Percutaneous Coronary Intervention for Acute Myocardial Infarction. media.jamanetwork.com. press-release. https://media.jamanetwork.com/media-releases/10.1001/jama.2026.17302
  8. Omerovic E, Koul S, Andersson J, et al. Prasugrel versus Ticagrelor in Acute Coronary Syndromes. The New England journal of medicine 2026. doi:10.1056/NEJMoa2609057. PMID: 42670968. https://pubmed.ncbi.nlm.nih.gov/42670968/
  9. Long-term intensive blood-pressure control reduces dementia risk. escardio.org. press-release. https://www.escardio.org/news/press/press-releases/long-term-intensive-blood-pressure-control-reduces-dementia-risk/
  10. JAMA Editors' Summary. 2026-2027 Respiratory Vaccine Effectiveness and Safety, Evolocumab for LDL Lowering Before Percutaneous Coronary Intervention, Digital Outreach to Increase Statin Refills, and more. podcast, 2026-09-04. https://edhub.ama-assn.org/jn-learning/audio-player/10.1001/jama.2026.16961
  11. This Week in Cardiology. Sep 04 2026 This Week in Cardiology. podcast, 2026-09-04. https://twicardiology.libsyn.com/sep-04-2026-this-week-in-cardiology
  12. EMCrit. PulmCrit Hot Take: PRAGUE-26 RCT on catheter-directed thrombolysis for intermediate-high risk PE. blog, 2026-08-31. https://emcrit.org/pulmcrit/kroupa/
  13. Medical Xpress. Catheter ablation does not improve quality of life related to atrial fibrillation. blog, 2026-08-31. https://medicalxpress.com/news/2026-08-catheter-ablation-quality-life-atrial.html
  14. Medical Xpress. Immediate evolocumab after a heart attack improves LDL-cholesterol goals but not early cardiovascular outcomes. blog, 2026-08-31. https://medicalxpress.com/news/2026-08-evolocumab-heart-ldl-cholesterol-goals.html

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