Beta-Blockers in Heart Failure With Preserved Ejection Fraction: A Declining Role in Contemporary Management

Heart failure with preserved ejection fraction (HFpEF) presents as a growing challenge, accounting for nearly half of all heart failure diagnoses. It is characterized as a clinical condition with normal ejection fraction but impaired diastolic function leading to reduced exercise capacity, frequent hospitalization, and increased mortality, especially in the elderly population with multiple comorbidities like atrial fibrillation, hypertension, and coronary artery disease. Beta-blockers (BBs) have historically been a primary therapy in patients with heart failure reduced ejection fraction due to their proven benefits on mortality and hospitalizations. Although BBs have been utilized in HFpEF for the management of comorbidities, their role in HFpEF remains uncertain and controversial. Clinicians have used BBs for targeted management of atrial fibrillation and ischemic heart disease. However, emerging research highlights the risks of BB-mediated amplification of chronotropic incompetence, reduction in cardiac output during exertion, and worsening symptoms in certain HFpEF phenotypes with low output, such as cardiac amyloidosis. These findings add to the already existing ambiguity from limited randomized trials and mixed results from observational studies and meta-analyses. This narrative review aims to synthesize the current data regarding BB use in HFpEF and explore their mechanistic rationale. Additionally, we seek to clarify the clinical indications and potential harms. Future research, including targeted trials, is still needed to further define the appropriate use of BBs in the population.