AHA Scientific Sessions 2026 Abstract · Nov 2, 2026
Beta-Blocker Initiation and Clinical Outcomes in Older Adults with Heart Failure with Preserved Ejection Fraction: A Target Trial Emulation
By Akman Z, Ibrahim S, Rossi R et al.
Background: Beta-blockers are commonly prescribed in patients with heart failure with preserved ejection fraction (HFpEF), although evidence supporting their use in older adults is limited. Research Question: How does beta-blocker initiation affect clinical outcomes among older adults with HFpEF? Methods: This target trial emulation used de-identified electronic health record data from the TriNetX Research Network. Adults aged ≥65 years with HFpEF (left ventricular ejection fraction ≥50%) were identified using a new-user design, excluding prior beta-blocker exposure. Patients were propensity score-matched 1:1 based on demographics, comorbidities, medications, and laboratory data. The study’s exposure was initiation of a beta-blocker vs no beta-blocker use at the time of HFpEF diagnosis. The primary outcome was all-cause mortality. Secondary outcomes included all-cause hospitalization, acute pulmonary edema, syncope, bradycardia, falls, and acute kidney injury (AKI). Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated using Cox proportional hazards models. Outcomes were assessed at 1 and 3 years Results: A total of 37,144 patients (mean age, 75.5 ± 6.2 years; 52.5% female) were included after propensity score matching (18,572 per group). Beta-blocker initiation was not associated with all-cause mortality at 1 year (HR, 1.024; 95% CI, 0.969-1.082; P = 0.40) or at 3 years (HR, 1.012; 95% CI, 0.966-1.061; P = 0.61). Beta-blocker use was associated with higher risks of all-cause hospitalization (HR, 1.550; 95% CI, 1.503-1.599; P <0.001), AKI (HR, 1.248; 95% CI, 1.185-1.315; P <0.001), falls (HR, 1.113; 95% CI, 1.026-1.207; P = 0.010), and bradycardia (HR, 1.074; 95% CI, 1.000-1.153; P = 0.049). No significant association was observed with acute pulmonary edema (HR, 1.043; 95% CI, 0.985-1.104; P = 0.15) or syncope (HR, 0.699; 95% CI, 0.465-1.053; P = 0.09) at 1 year. Conclusion: Among older adults with HFpEF, beta-blocker initiation was not associated with reduced mortality but was associated with increased hospitalization and adverse events. These findings do not support routine beta-blocker use in this population and highlight the need for prospective randomized trials to address this common clinical scenario.