What changed recently

The 2025 guideline replaces the 2021 edition and moves mitral intervention earlier: repair surgery becomes a Class I option in selected asymptomatic primary mitral regurgitation, and transcatheter edge-to-edge repair is upgraded to Class I in symptomatic severe ventricular secondary regurgitation with reduced ejection fraction, with new recommendations added for atrial secondary regurgitation.

Updating the 2021 ESC/EACTS guideline, the 2025 version lowers the age cut-off favouring transcatheter aortic valve implantation in tricuspid aortic stenosis from 75 to 70 years, tightens the echocardiographic criteria for grading stenosis severity, and lowers thresholds for intervening earlier.

2025 focused update of the 2019 ESC/EAS guideline, incorporating newer lipid-lowering trial evidence while retaining risk-based LDL-C goals.

First full US revision since 2017: adopts the PREVENT equations for risk estimation (replacing the Pooled Cohort Equations) and reaffirms a <130/80 mm Hg treatment goal.

The 2025 guideline consolidates the 2013 STEMI, 2014 NSTEMI and 2015 primary-PCI focused update into one document covering the whole ACS spectrum, and refreshes post-infarction antithrombotic and revascularisation guidance, including intracoronary imaging to guide PCI and revised anticoagulant choices.

The 2025 guideline merges the separate 2013 STEMI and 2014 NSTEMI documents (plus the 2015 primary-PCI focused update) into a single guideline spanning unstable angina, NSTE-ACS and STEMI. New positions include a recommendation to use intracoronary imaging to guide PCI, a weak (Class 2b) option for bivalirudin in NSTE-ACS to limit bleeding, and advice against fondaparinux as the sole anticoagulant during PCI.

Replacing the 2017 ESC peripheral arterial diseases guideline and merging it with aortic disease guidance, the 2024 document keeps single antiplatelet therapy as the Class I default in symptomatic peripheral artery disease but adds dual pathway inhibition with low-dose rivaroxaban plus aspirin for patients at high ischaemic and low bleeding risk, including after lower-limb revascularisation.

For the first time the ESC merges its 2014 aortic diseases and 2017 peripheral arterial diseases guidelines into a single document, treating the arterial system as a whole. It sets a Class I threshold of 55 mm maximum aortic diameter for surgery in both tricuspid and bicuspid aortic valve patients, with 50 mm for the bicuspid root phenotype, and pushes management towards experienced multidisciplinary aortic teams.

Reorganizes AF management around the patient-centred AF-CARE pathway, foregrounding comorbidity and risk-factor management.

Introduces a new 'Elevated BP' category (120–139/70–89 mm Hg) and a 120–129/70–79 mm Hg on-treatment target for most adults, with a Class I emphasis on out-of-office measurement.

The 2024 multisociety guideline updates the 2016 AHA/ACC lower extremity peripheral artery disease guideline and reorganises care around four clinical presentations - asymptomatic disease, chronic symptomatic disease, chronic limb-threatening ischaemia and acute limb ischaemia. It adds recommendations on identifying PAD risk amplifiers and health disparities and on structured medical and lifestyle therapy within a team-based care plan.

Following STRONG-HF, the 2023 focused update adds a Class I recommendation that patients hospitalised for heart failure have evidence-based therapy rapidly up-titrated before discharge with close follow-up over the first six weeks, replacing the more permissive post-discharge approach of the 2021 guideline.

The 2023 focused update strengthens intravenous iron repletion with ferric carboxymaltose or ferric derisomaltose for iron-deficient patients with reduced or mildly reduced ejection fraction to reduce heart failure hospitalisation, and adds guidance on comorbidities such as chronic kidney disease and diabetes on top of the 2021 four-pillar therapy.

Acting on EMPEROR-Preserved and DELIVER, the 2023 focused update gives dapagliflozin or empagliflozin a Class I recommendation in preserved and mildly reduced ejection fraction to cut heart failure hospitalisation and cardiovascular death, a treatment the 2021 guideline could not recommend.

The 2023 ESC guideline supersedes the separate 2017 STEMI and 2020 NSTE-ACS documents and treats long-term management after hospital discharge as an integral part of ACS care, with updated antithrombotic and secondary-prevention guidance across the whole spectrum.

For the first time the ESC covers the entire ACS spectrum in a single document, replacing the separate 2017 STEMI and 2020 NSTE-ACS guidelines. It rebuilds guidance on initial diagnosis and risk stratification, antithrombotic therapy, and the timing of invasive assessment and revascularisation.

Replaces the 2014 guideline and 2019 focused update: introduces a four-stage AF classification, emphasizes early rhythm control, and positions catheter ablation as first-line in selected patients.

The 2022 guideline updates the 2010 thoracic aortic disease guideline and, for the first time, covers the thoracic and abdominal aorta in one document. In experienced multidisciplinary centres it lowers the repair threshold for sporadic root and ascending aneurysms to 5.0 cm in selected patients, and formalises body-size indexed measures such as aortic size index and aortic height index for smaller or taller patients.

Updating the 2015 ESC guideline, the 2022 version gives catheter ablation a larger role, including in patients without structural heart disease and in stable coronary disease with only mildly reduced ejection fraction, and moves risk stratification beyond ejection fraction alone by adopting disease-specific risk calculators for laminopathy and long QT syndrome alongside the existing hypertrophic cardiomyopathy score.

The 2022 guideline replaces the 2013 guideline and its 2017 focused update, adds SGLT2 inhibitors to standard therapy, and broadens the document with new sections on cardiac amyloidosis, cardio-oncology, comorbidity management and advanced (stage D) therapies.

Replacing the 2013 guideline and 2017 focused update, the 2022 document redefines the heart failure stages around 'at risk' and 'pre-heart failure', formalises the mildly reduced ejection fraction category, and for the first time gives SGLT2 inhibitors a positive recommendation in preserved and mildly reduced ejection fraction.

The 2022 guideline replaces the 2013 ACCF/AHA heart failure guideline and its 2017 focused update, and expands guideline-directed medical therapy for reduced ejection fraction to four drug classes by adding SGLT2 inhibitors alongside renin-angiotensin system inhibition or ARNI, beta blockers and mineralocorticoid receptor antagonists.

Superseding the 2013 ESC/EHRA pacing guideline, the 2021 version adds an entirely new section on conduction system pacing (His bundle and left bundle branch area pacing), expands and revises the CRT indications in line with the heart failure task force, and adds recommendations for preventing pacing-induced cardiomyopathy plus guidance on MRI, irradiation and remote monitoring.

The second CHEST update revises the 2016 VTE guideline with four new questions and eight substantially modified statements, and defines anticoagulation phases explicitly - an initiation phase of about 5 to 21 days followed by a treatment phase of roughly 12 weeks - to structure decisions on drug choice and duration.

This second update revises the 2016 CHEST VTE guideline, adding four previously unaddressed questions and substantially modifying eight earlier statements across 32 guidance statements. It also introduces explicit phase-of-anticoagulation nomenclature, separating an initiation phase of about 5 to 21 days from a treatment phase of roughly 12 weeks.

Superseding the 2014 guideline and 2017 focused update, the 2020 guideline expands the role of transcatheter mitral repair and directs complex mitral surgery to comprehensive valve centres, while restructuring intervention thresholds around valve-related symptoms, ventricular consequences and life expectancy.

Replacing the 2014 guideline and its 2017 focused update, the 2020 document reframes the choice between surgical and transcatheter aortic valve replacement around patient age and life expectancy rather than surgical risk category, extends transcatheter replacement to selected bicuspid valve stenosis, and introduces primary and comprehensive valve centre requirements.

Updating the 2014 ESC guideline, the 2019 version makes direct oral anticoagulants the first-line treatment (Class I) except in severe renal impairment, pregnancy or antiphospholipid syndrome, supports early discharge and home treatment for carefully selected low-risk patients, and adds a structured 3 to 6 month follow-up pathway to detect post-PE dyspnoea and chronic thromboembolic pulmonary hypertension.

Replacing the 2013 ACC/AHA cholesterol guideline, the 2018 version reintroduces LDL cholesterol thresholds to trigger treatment intensification - roughly 70 mg/dL in very high-risk secondary prevention - and endorses adding ezetimibe first and then a PCSK9 inhibitor to maximally tolerated statin. It also adds risk-enhancing factors and coronary artery calcium scoring to refine statin decisions in intermediate-risk primary prevention.

This is the first US guideline devoted specifically to bradycardia and conduction delay; it supersedes the pacemaker recommendations of the 2008 ACC/AHA/HRS device-based therapy guideline and its 2012 focused update, reorganising them around evaluation of the bradycardic patient rather than around device indications.

The 2017 guideline replaces the 2006 ACC/AHA/ESC ventricular arrhythmia guideline, and also supersedes the ICD indication sections of the 2008 device-based therapy guideline and updates the sudden-death prevention advice in the 2011 hypertrophic cardiomyopathy guideline, consolidating ventricular arrhythmia and sudden cardiac death management in one document.