Beta Blockers in Heart Failure with Preserved Ejection Fraction (HFpEF)

Pathophysiological Considerations

Beta blockers reduce heart rate, which can be detrimental in HFpEF patients who rely on adequate chronotropic response during exercise to maintain cardiac output, as noted by the American College of Cardiology and Hypertension guidelines 1, 2
Chronotropic incompetence is a key contributor to exercise intolerance in HFpEF patients, according to the American College of Cardiology 1

The American Heart Association, American College of Cardiology, and Heart Failure Society of America guidelines note that beta blockers may contribute to exercise intolerance in HFpEF patients due to chronotropic incompetence 1
Beta blockers are only recommended in HFpEF patients with specific comorbid indications, such as history of myocardial infarction, symptomatic coronary artery disease, or atrial fibrillation with rapid ventricular response, as recommended by the American College of Cardiology and Hypertension guidelines 1, 2
The American College of Cardiology recommends SGLT2 inhibitors as first-line disease-modifying therapy for HFpEF, based on the EMPEROR-Preserved trial, which showed a 21% reduction in the primary composite endpoint of heart failure hospitalization or cardiovascular death 1

The American College of Cardiology recommends SGLT2 inhibitors, such as dapagliflozin, as first-line therapy for HFpEF, based on the DELIVER trial, which demonstrated a significant reduction in heart failure hospitalizations and composite cardiovascular outcomes 1
Mineralocorticoid receptor antagonists, such as spironolactone, are recommended for patients with LVEF in the lower range of preservation, according to the American College of Cardiology 1
RAAS antagonists, including ACEi, ARB, and possibly ARNi, are recommended as first-line agents for hypertension management in HFpEF, as noted by the American College of Cardiology 1

The American College of Cardiology recommends reserving beta blockers for HFpEF patients with specific indications, and monitoring for signs of exercise intolerance and considering dose adjustment if symptoms worsen 1, 2
For HFpEF patients with atrial fibrillation, the American College of Cardiology recommends considering alternatives to beta blockers for rate control if patients experience adverse effects 1

The American Heart Association and American College of Cardiology guidelines note that beta blockers lack proven efficacy for the primary HFpEF syndrome itself, with no mortality benefit demonstrated 3
Beta blockers are indicated for patients with HFpEF who have specific comorbid conditions, such as post-myocardial infarction 3, 4
The American College of Cardiology recommends beta blockers for symptomatic angina or coronary artery disease in HFpEF patients 3, 4
Atrial fibrillation requiring rate control is another indication for beta blockers in HFpEF patients, though alternatives may be preferable if adverse effects occur 3
Hypertension requiring additional blood pressure control is also an indication for beta blockers in HFpEF patients, according to the American Heart Association 5, 4
Tachycardia with heart rate >80 bpm is an indication for beta blockers in HFpEF patients 3

High utilization of beta blockers in clinical trials, with 72-87% of patients on beta blockers as add-on therapy for comorbidities 3, 6, 7, 8
Recent analyses show beta blocker use was not associated with higher risk of worsening HF or cardiovascular death in HFpEF patients, with a strength of evidence considered moderate 3

The American College of Cardiology recommends SGLT2 inhibitors (dapagliflozin or empagliflozin) as first-line disease-modifying therapy for HFpEF, with proven reduction in HF hospitalizations and cardiovascular mortality 9
Mineralocorticoid receptor antagonists (spironolactone) are recommended for patients with LVEF closer to 45-50% 5
Loop diuretics are recommended for symptom management and congestion relief in HFpEF patients 5

If a HFpEF patient is already on a beta blocker, assess whether there is a specific indication (prior MI, CAD, AF, hypertension) and consider dose reduction or discontinuation if symptoms worsen 5
If initiating new therapy for HFpEF, start with SGLT2 inhibitor as disease-modifying therapy and reserve beta blockers only for patients with specific comorbid indications 5, 9