What is the best beta blocker for a patient with heart failure with preserved ejection fraction (HFpEF) who is also on Entresto (sacubitril/valsartan)?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: July 31, 2025 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Best Beta Blocker for Heart Failure with Preserved Ejection Fraction in a Patient on Entresto

There is no specific beta blocker that has demonstrated superior efficacy for heart failure with preserved ejection fraction (HFpEF) in patients on Entresto (sacubitril/valsartan), and beta blockers are not routinely recommended as primary therapy for HFpEF unless there are specific comorbid indications.

Beta Blockers in HFpEF

Evidence and Recommendations

  • According to the 2023 ACC Expert Consensus Decision Pathway on management of HFpEF, beta blockers may be used in HFpEF patients only for specific indications 1:

    • Prior myocardial infarction (for up to 3 years)
    • Angina
    • Atrial fibrillation rate control

  • Unlike in heart failure with reduced ejection fraction (HFrEF), beta blockers have not demonstrated mortality benefits in HFpEF patients 1

  • Historical trials of beta blockers in HFpEF have shown negative or neutral results 1

  • Exercise tolerance should be monitored in HFpEF patients on beta blockers due to the potential for chronotropic incompetence 1

Beta Blocker Selection for Specific Indications

If a beta blocker is indicated for a comorbid condition in a HFpEF patient on Entresto, the following options should be considered:

  1. For rate control in atrial fibrillation:

    • Metoprolol succinate (extended-release) - starting at 12.5-25mg daily, target 200mg daily
    • Bisoprolol - starting at 1.25mg daily, target 10mg daily
    • Carvedilol - starting at 3.125mg twice daily, target 25mg twice daily (for weight <85kg) or 50mg twice daily (for weight ≥85kg)

  2. For post-myocardial infarction or angina:

    • Any of the three evidence-based beta blockers (metoprolol succinate, bisoprolol, or carvedilol) can be used 1

Primary Therapies for HFpEF

Instead of focusing on beta blockers, the following medications have demonstrated benefit in HFpEF and should be prioritized:

  1. SGLT2 inhibitors (dapagliflozin or empagliflozin) - shown to reduce hospitalization for heart failure and cardiovascular death in HFpEF patients 1

  2. Mineralocorticoid receptor antagonists (MRAs) like spironolactone - may benefit selected HFpEF patients 1

  3. Entresto (sacubitril/valsartan) - the patient is already on this medication, which has shown some benefit in HFpEF, particularly in patients with LVEF below normal but not reduced enough to be classified as HFrEF 1

  4. Diuretics - for symptom management of congestion 1

Monitoring and Cautions

  • If a beta blocker is prescribed for a specific indication, monitor for:

    • Worsening exercise tolerance
    • Bradycardia
    • Hypotension
    • Fatigue

  • Start at low doses and titrate slowly in HFpEF patients

  • Avoid beta blockers in patients with severe reactive airway disease, symptomatic bradycardia, or advanced heart block 1

  • The combination of Entresto with beta blockers requires careful monitoring of blood pressure, as both can cause hypotension

Conclusion

For a HFpEF patient on Entresto, there is no evidence supporting the routine use of any specific beta blocker for the primary treatment of HFpEF. Beta blockers should only be used for specific comorbid indications, with careful monitoring of exercise tolerance and potential side effects. Focus treatment on optimizing SGLT2 inhibitors, MRAs, and diuretics as needed for symptom management.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Related Questions

For heart failure with reduced ejection fraction, which is preferred, metoprolol tartrate or metoprolol succinate (beta blockers)?
What is the equivalent dosage of metoprolol (Beta-1 selective Beta blocker) when converting from atenolol (Beta-1 selective Beta blocker)?
What are beta blockers (beta-adrenergic blocking agents)?
What is the role of beta blockers, specifically bisoprolol (Beta-1 selective blocker), in Guideline-Directed Medical Therapy (GDMT) for patients with heart conditions?
Is there evidence for the use of Entresto (sacubitril/valsartan) in Heart Failure with preserved Ejection Fraction (HFpEF)?
What are the next steps in managing a patient with mild atherosclerotic calcification of the coronary arteries and thoracic aorta?
What is the treatment for acetaminophen (Tylenol) overdose in pediatric patients?
What are the guidelines for managing hyperlipidemia?
What is the recommended dosing for ceftolozane/tazobactam (Cefotaxime/Tazobactam) in patients with impaired renal function?
What is the treatment for acetaminophen (Tylenol) overdose in pediatric patients?
What should a pregnant person in their first trimester do if exposed to cat litter?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question