Which beta-blockers are proven to improve survival in HFrEF?

• A. Propranolol only.
• B. Metoprolol tartrate only.
• C. Carvedilol, metoprolol succinate, and bisoprolol.
• D. Atenolol only.

Answer: (C)

In HFrEF, not all beta-blockers have been shown to improve survival; only certain ones have robust mortality benefits from major trials. The best choice includes the three beta-blockers that provenly reduce death in this setting: carvedilol, metoprolol succinate, and bisoprolol. Carvedilol, studied in COPERNICUS, showed clear reductions in all-cause mortality in patients with severe systolic heart failure. Metoprolol succinate, evaluated in MERIT-HF, demonstrated a mortality benefit when added to standard therapy. Bisoprolol was shown to improve survival in CIBIS-II. These results underpin guideline recommendations to use these agents in stable HFrEF as part of comprehensive medical therapy, titrating to target doses.

Other beta-blockers lack the same proven mortality benefit in HFrEF. Propranolol hasn’t demonstrated mortality reduction in this population, and metoprolol tartrate is not the form proven to improve survival (the trials used metoprolol succinate). Atenolol similarly lacks consistent mortality benefit in HFrEF.