Letter to the Editor: Beta-blockers vs calcium channel blockers in heart failure with preserved ejection fraction: An old question in need of new answers

Table 1 Summary about beta-blockers and calcium channel blockers

Topic	Ref.	Beta-blockers	Calcium channel blockers
Mechanism of action	Arnold et al[2], 2023; Wernhart et al[3], 2023; Meyer et al[4], 2023; Matsumoto et al[5], 2023	Reduce heart rate, myocardial oxygen demand, and blood pressure	Dihydropyridines cause vasodilation and BP reduction; non-dihydropyridines also reduce heart rate and have negative inotropic effects
Clinical use	Meyer et al[4], 2023; Matsumoto et al[5], 2023; Martin et al[7], 2021	Potential benefit in patients with concomitant CAD or AF	Non-dihydropyridines preferred for rate control in AF; dihydropyridines are mainly used for hypertension
Safety and adverse effects	Wernhart et al[3], 2023; Martin et al[7], 2021	Can worsen chronotropic incompetence and exercise intolerance, particularly in HFpEF without AF or CAD	Generally well tolerated; non-dihydropyridines may cause bradycardia and conduction disturbances
Efficacy in HFpEF	Meyer et al[4], 2023; Matsumoto et al[5], 2023; Wu et al[6], 2023; Martin et al[7], 2021; Liu et al[8], 2014; Bavishi et al[9], 2015	May modestly reduce cardiovascular mortality, but evidence certainty is low; inconsistent effects on all-cause mortality and HF hospitalization	Generally neutral or modestly protective for HF hospitalization and pump failure death, without increased mortality
Comparative outcomes	Arnold et al[2], 2023; Wernhart et al[3], 2023; Meyer et al[4], 2023; Martin et al[7], 2021	Benefits are more pronounced in HFpEF with CAD or AF; neutral or potentially harmful in patients without these comorbiditie	Non-dihydropyridines may be associated with lower HF hospitalization risk compared to beta-blockers, especially in HFpEF with AF
Strength of evidence	Joseph et al[1], 2019; Meyer et al[4], 2023; Wu et al[6], 2023; Martin et al[7], 2021; Liu et al[8], 2014; Bavishi et al[9], 2015	Meta-analyses, RCTs, and observational studies; results inconsistent	Mostly observational studies; limited RCT data
Clinical scenarios favoring use	Arnold et al[2], 2023; Meyer et al[4], 2023; Martin et al[7], 2021	HFpEF with AF or CAD	Hypertension, AF (rate control), or intolerance to beta-blockers due to exercise limitation

BP: Blood pressure; CAD: Coronary artery disease; AF: Atrial fibrillation; HFpEF: Heart failure with preserved ejection fraction; HF: Heart failure; RCT: Randomized controlled trial.