The β-blockers dilemma in HFpEF: indicated, inert, or harmful?

This editorial refers to ‘Are β-blockers necessary for patients with heart failure with preserved ejection fraction? PURSUIT-HFpEF registry, by M. Nishino et al., https://doi.org/10.1093/ejhf/xuag071. The difficulty lies not so much in developing new ideas as in escaping from old ones John Maynard Keynes (Economist, father founder of macroeconomics) Beta-blockers are a cornerstone of therapy in heart failure (HF) with reduced ejection fraction, with consistent and reproducible reductions in mortality and hospitalizations.1,2 While some evidence extends these benefits into the mildly reduced ejection fraction range,2 their use in HF with preserved ejection fraction (HFpEF) has historically relied more on extrapolation and comorbidity management than on direct proof of benefit (Figure 1). Despite this limited HFpEF-specific evidence, β-blockers remain commonly prescribed in this setting. In this issue of the European Journal of Heart Failure, Nishino et al. report findings from the PURSUIT-HFpEF (Prospective, mUlticenteR, obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction) registry,3 aiming to provide further evidence on the effects of β-blockers in HFpEF. Interestingly, rather than treating β-blocker exposure as a homogeneous variable, the investigators adopt a clinically meaningful approach by stratifying patients according to comorbidities that traditionally warrant their use, namely atrial fibrillation (AF) and ischaemic heart disease (IHD). Their principal finding is two-fold: first, among HFpEF patients without AF or IHD, β-blocker use was associated with higher risks of all-cause mortality, cardiac mortality, and the composite of mortality and HF hospitalization; second, and perhaps equally striking, no clear protective association was observed in patients with AF or IHD, subgroups in whom β-blockers are most commonly used and justified.