ESC Congress 2026 Abstract · Oct 26, 2026

Beta-blocker dose titration, functional capacity, and all-cause mortality in patients with heart failure and reduced ejection fraction

By Berge K, Stenseth PR, Ovrebotten T et al.

Background: Physical activity is recommended as part of comprehensive heart failure (HF) management alongside pharmacotherapy to improve outcomes. Treatment with beta-blockers (BB) reduces mortality and improves HF symptoms but may also impair exercise capacity due to BB-induced chronotropic incompetence. Purpose: To explore the association between change in BB dose during GDMT titration, physical activity, and mortality in patients with chronic HF with reduced left ventricular ejection fraction (LVEF). Methods: We analysed all HF patients with an LVEF ≤40% registered in the Norwegian Heart Failure Registry from 2013–2025 who had self-reported physical activity and 6-minute walking test (6MWT) data available at the first and last visit during guideline-directed medical therapy (GDMT) titration follow-up. Patients were stratified according to change in BB dose during follow-up, and associations with changes in physical activity and 6MWT were analysed using linear and logistic regression. Cox regression was used to determine associations with all-cause mortality. All models were adjusted for age, sex, body mass index, smoking status, HF aetiology, LVEF, blood pressure, heart rate, NYHA functional class, comorbidities, NT-proBNP, eGFR, and haemoglobin, and use of ACEi/ARBs/ARNIs, MRA, and SGLT2i. Results: In total, 16,441 patients (mean age 68.4±11.8 years; 24.6% females) were included. After a median (IQR) up-titration period of 143 (81–239) days, 40% had escalated BB therapy, 48% had no change, and 12% had reduced the BB dose. In adjusted analyses, BB dose reduction was associated with a small increase in absolute 6MWT distance (6.32 meters [95% CI 1.58 – 11.07]) but with a 25% higher likelihood of decreasing light physical activity (RRR 1.25 [1.02–1.53]). BB dose escalation was associated with a decrease in absolute 6MWT distance (-6.53 meters [-9.67 – -3.38)) but with a 23% higher likelihood of increasing light physical activity (RRR 1.23 [1.07–1.42]) and 13% higher likelihood of increasing vigorous physical activity (RRR 1.13 [1.02–1.25]). Changes in BB dose during the titration visits were not associated with all-cause mortality during one year of follow-up after the last titration visit. Increased 6WMT and vigorous physical activity during follow-up were associated with reduced all-cause mortality risk (HR 0.53 [0.42–0.67] and HR 0.45 [0.35–0.60], respectively), whereas increased light physical activity was not associated with all-cause mortality. Conclusion: During GDMT titration in HFrEF, BB dose adjustments were associated with small, divergent changes in 6MWT distance and self-reported physical activity, but not with one-year all-cause mortality. Improvements in 6MWT distance and increases in vigorous physical activity were associated with lower 1-year mortality. This underscores the complexity of optimizing BB therapy in HFrEF and supports an individualized approach to BB dosing.

doi.org/10.1093/eurheartj/ehag785.1307 Open access Populations