Heart Failure With Preserved Ejection Fraction and Atrial Fibrillation: Are Beta-Blockers Still Relevant?

BBs can worsen symptoms and exercise capacity.Moreover, there is evidence that increasing HR through atrial pacing in an HFpEF population can reduce left ventricular end-diastolic filling pressure. 8)Furthermore, BBs in HFpEF can worsen exercise capacity, which can be reversed after withdrawing BBs. 9,10)e effects of BBs on clinical outcomes in patients with HFpEF remain unclear.One major factor contributing to this uncertainty is the lack of large-scale, randomized controlled trials targeting patients with HFpEF treated with BBs.In the Study of Effects of Nebivolol Intervention on Outcomes and Rehospitalization in Seniors With Heart Failure (SENIORS) trial, approximately 36% of enrolled patients had left ventricular ejection fraction (LVEF) greater than 35%, and post-hoc analysis suggested a potential association between nebivolol use and improved LVEF. 11)However, many of these patients met the HF category of mildly reduced LVEF, limiting the findings' applicability to true HFpEF populations and failing to demonstrate improved clinical outcome.A meta-analysis of patients with LVEF greater than 40% also found no evidence that BBs improved clinical outcomes. 12)Atrial fibrillation (AF) is common in HFpEF, and doubles the risk of mortality, serving as a poor prognostic marker. 13)However, few studies have explored the efficacy of BBs in patients with HFpEF and AF.In this issue of the International Journal of Heart Failure, Kim et al. 14) analyzed 687 patients from the Korean Acute Heart Failure (KorAHF) registry, who were hospitalized with acute HF and presented with LVEF 50% and concomitant AF.The study divided patients into high and low HR groups based on a median heart rate of 75 bpm and analyzed outcomes based on BBs prescription at discharge.While no difference was observed in the low HR group, the high HR group showed notably reduced rehospitalization events with BB use.Although studies on BBs in HFpEF with AF are scarce, some retrospective studies have reported improved clinical outcome with BBs. 15,16)