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Does the purported mortality benefit of beta-blocker therapy in heart failure with a preserved ejection fraction apply to patients without prior myocardial infarction?
  1. Nilay Kumar
  1. Correspondence to Dr Nilay Kumar, Department of Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI 53706, USA; nkumar39{at}

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To the Editor We read with interest the study by Zheng et al in which the authors conducted a meta-analysis of randomised controlled trials to evaluate the effect of different drug classes in heart failure with a preserved ejection fraction (HFpEF). Primary outcome was all-cause mortality and secondary outcome was cardiovascular mortality among other secondary outcomes. The authors found that beta-blocker therapy led to significant reductions in all-cause mortality (relative risk 0.78, 95% CI 0.65 to 0.94, P=0.008) and cardiovascular mortality (0.71, 95% CI 0.55 to 0.93).1 These pooled effect estimates were driven by one study by Aronow et al, which constitutes 63.7% of the weight for the pooled effect estimate for all-cause mortality and 72.8% of the weight for the pooled effect estimate for cardiovascular mortality. This trial conducted in the 1990s exclusively enrolled patients with HFpEF with prior myocardial infarction (MI).2 Other trials from the pre-reperfusion era have shown similar reductions in all-cause and cardiovascular mortality with beta-blockers in patients with MI.3 Professional society guidelines recommend initiation of beta-blocker therapy within 24 hours of acute coronary syndrome and continuation for a minimum of 3 years.4 In contrast with the homogeneous study population with prior MI in the study by Aronow et al which drove the results of this meta-analysis, the real-world population of patients with HFpEF is characterised by heterogeneity in clinical presentation, comorbidity burden, echocardiographic characteristics and biomarker profile. As a result of the inclusion of the Aronow study in which all patients had a prior MI, the pooled effect estimates presented in the current study are likely to be systematically biased in favour of beta-blocker use. Clinicians must exercise caution against a blanket prescription of beta-blockers in HFpEF based on the results of this study as the mortality benefit seen here is unlikely to apply to patients without a recent history of myocardial infarction.



  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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