Which of the following beta-blockers is not listed among the licensed heart failure therapies?

• A. Nebivolol
• B. Bisoprolol
• C. Carvedilol
• D. Propranolol

Answer: (D)

In heart failure with reduced ejection fraction, therapies are guided by robust evidence showing mortality and morbidity benefits. The beta-blockers with clear, Lancet/major guideline-backed benefit and licensing for HF are carvedilol, bisoprolol, and metoprolol succinate. Nebivolol appears in some guidelines or regions due to trial data in older patients, but licensing can vary by country. Propranolol, a nonselective beta-blocker, does not have HF-specific trials showing a mortality benefit and its strong negative inotropic effect can worsen heart failure symptoms. Because of this, propranolol is not licensed as a heart failure therapy in the standard treatment repertoire, which is why it is not listed among licensed HF therapies.