Key result
New 2025 ISHLT guidelines update pediatric HF pharmacotherapy and introduce an EF-based classification.
Why the study?
Pediatric heart failure remains a major cause of childhood morbidity and mortality, and the 2025 ISHLT guidelines provide an updated framework while underscoring persistent gaps in pediatric-specific evidence.
The 2025 ISHLT Guidelines provide a contemporary framework for the pharmacologic management of pediatric heart failure, introducing an EF-based classification and updating recommendations for novel therapies while highlighting persistent evidence gaps.
May inform pediatric HF pharmacotherapy; leaves open evidence gaps in HFpEF and complex congenital disease.
Backgrounds: Pediatric heart failure (PHF), most commonly resulting from cardiomyopathies, congenital heart disease, or acquired cardiac disorders, remains a major cause of childhood morbidity and mortality. The 2025 International Society for Heart and Lung Transplantation (ISHLT) guidelines provide the most comprehensive update in over a decade, offering a contemporary framework for pharmacologic management when underscoring persistent gaps in pediatric-specific evidence. Methods: This narrative review synthesizes the 2025 ISHLT Guidelines alongside contemporary pediatric and adult HF guidance, emphasizing pharmacologic recommendations, areas of extrapolation from adult trials, and persistent evidence gaps across diverse PHF phenotypes. Results: The updated guideline introduces an ejection fraction (EF)-based classification system and refines pharmacologic recommendations for acute and chronic PHF. It reaffirms Class I support for foundational neurohormonal therapies in PHF with reduced EF, incorporates randomized control trial-based recommendations for sacubitril–valsartan and ivabradine, and offers limited, extrapolated recommendations for agents such as sodium–glucose cotransporter-2 inhibitors, mineralocorticosteroid receptor antagonists, and soluble guanylate cyclase stimulators. The guideline also outlines phenotype-specific considerations for high-risk groups, including congenital heart disease and cancer therapy-related cardiomyopathy. Persistent unmet needs include the absence of disease-modifying therapies for PHF with preserved EF and insufficient evidence to guide management of complex congenital and syndromic conditions. Conclusion: The 2025 ISHLT Guidelines provide a structured, contemporary approach to pharmacologic therapy in PHF when clearly delineating areas where evidence remains limited. Addressing these limitations will require coordinated multicenter research, real-world data integration, and learning health systems capable of translating emerging therapies into evidence-based pediatric practice.
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Bibhuti B. Das (2026) conducted a review in Pediatric heart failure. 2025 ISHLT Guidelines for pharmacologic therapy was evaluated. The 2025 ISHLT Guidelines provide updated pharmacologic recommendations for pediatric heart failure, introducing an ejection fraction-based classification while highlighting persistent evidence gaps.
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