Which statement best describes the set of beta-blockers licensed for heart failure?

• A. Nebivolol
• B. Bisoprolol
• C. Carvedilol
• D. All of the above

Answer: (D)

Starting with what beta-blockers in heart failure do: in heart failure with reduced ejection fraction (HFrEF), certain beta-blockers have been shown in large trials to reduce mortality and hospitalizations by dampening the harmful effects of chronic sympathetic activation on the heart. Only specific agents have established licensing for this indication based on those trials.

Carvedilol, bisoprolol, and nebivolol all have evidence from major studies supporting their benefit in HFrEF, and they are licensed for this use in many guidelines and formularies. Carvedilol’s benefit comes from trials like COPERNICUS, bisoprolol from CIBIS-I/II, and nebivolol from the SENIORS trial in elderly patients, broadening its applicable population. Because all three have regulatory approval for heart failure in at least some settings, the statement that all of the above are licensed for heart failure best fits the evidence and regulatory status.

In practice, dosing starts low and is uptitrated carefully, with monitoring for tolerance, but the key point is that each of these three agents is recognized as a licensed option for heart failure in the appropriate patient groups.