Beta-Blocker Use in HF and AF: Insights from India's Landmark ROBUST Study

Beta-blockers have long been a cornerstone in the management of cardiovascular diseases, particularly heart failure (HF) and atrial fibrillation (AF). While clinical trials have established their efficacy, data on how these agents are used in routine clinical practice in India have been limited. The recently published Role of β-Blockers Across the Cardiovascular Continuum: A Real-World Perception Survey (ROBUST) bridges this gap by providing valuable insights into the prescribing behaviour and treatment preferences of Indian healthcare professionals managing cardiovascular diseases.

Published in the Journal of the Association of Physicians of India in 2026, the nationwide cross-sectional clinical survey included responses from 855 healthcare professionals, comprising consulting physicians, cardiologists and specialists in diabetes and metabolism. The study assessed prescribing patterns, perceived benefits and barriers to beta-blocker use across different cardiovascular conditions, offering a real-world perspective on current clinical practice in India.

Beta-Blockers Continue to Play a Central Role in Heart Failure

The ROBUST survey reaffirms the importance of beta-blockers in heart failure management. Among respondents, 43.2% identified beta-blockers as the therapy providing the greatest mortality benefit for patients with heart failure with reduced ejection fraction (HFrEF) at discharge, ahead of angiotensin receptor-neprilysin inhibitors (ARNIs), which were selected by 36.6% of clinicians. These findings reflect the continued confidence of physicians in beta-blockers as a key component of guideline-directed medical therapy (GDMT) for HFrEF.

In routine outpatient practice, 44.6% of healthcare professionals reported prescribing beta-blockers to 25–50% of their heart failure patients, while nearly one-third prescribed them to more than 75% of patients. The findings suggest that although beta-blockers remain widely used, there is likely potential for broader implementation in eligible patients.

Clinical Challenges Continue to Influence Prescribing Decisions

Despite recognizing the benefits of beta-blockers, physicians reported several practical challenges that affect treatment decisions. Among surveyed healthcare professionals (HCPs), 61.6% identified low heart rate as the most common reason for withholding β-blocker therapy in patients with heart failure, followed by low blood pressure (27.7%). These concerns highlight the need for careful patient selection and dose titration while balancing the proven cardiovascular benefits of these agents.

Interestingly, beta-blockers also continue to be used in patients with heart failure with preserved ejection fraction (HFpEF). More than half of the respondents reported prescribing them "most of the time" in HFpEF, reflecting their use for symptom control and heart rate management in routine practice.

Metoprolol Emerges as the Preferred Beta-Blocker in Heart Failure & Atrial Fibrillation

Among the different beta-blockers available in India, metoprolol emerged as the most preferred choice across cardiovascular indications. In heart failure, 66.2% of clinician respondents identified metoprolol as their preferred beta-blocker, followed by bisoprolol (21.3%) and carvedilol (15%).

The preference for metoprolol was even more pronounced in atrial fibrillation. For ventricular rate control in AF, 85.4% of healthcare professionals selected metoprolol, making it the most widely preferred beta-blocker for managing the condition. The survey findings indicate significant strong physician confidence in metoprolol for achieving effective heart rate control across diverse cardiovascular settings.

Cardiologists Report Higher Beta-Blocker Utilization

A subset analysis of cardiologists revealed even greater adoption of beta-blockers compared to the overall respondent group. More than 97% of cardiologists reported prescribing beta-blockers in outpatient heart failure with reduced ejection fraction management, while over 95% used them in patients with chronic coronary syndrome and following myocardial infarction. These findings underscore the strong acceptance of beta-blockers among cardiovascular specialists and their integral role in contemporary cardiac care.

Key Findings

• Beta-blockers were widely prescribed in heart failure, with physicians recognizing their significant role in HFrEF management.

• Atrial fibrillation (AF) recorded the highest preference for metoprolol among all cardiovascular indications evaluated in the study.

• Low heart rate and low blood pressure were the most common reasons for withholding beta-blocker therapy in heart failure.

• Cardiologists reported higher beta-blocker utilization across heart failure and other cardiovascular indications than the overall Indian clinician respondent group.

Metoprolol as a Preferred Beta-Blocker for Atrial Fibrillation in India

Speaking to Medical Dialogues, Dr Devanu Ghosh Roy, MBBS, Cardiology, M.D.(PGI), DM (CARD), MRCP (UK), FRCP (LOND), said- "In atrial fibrillation, metoprolol offers predictable and reliable ventricular rate control because of its selective β1-blockade. It reduces AV nodal conduction and controls resting and exertional heart rate without the broader peripheral effects associated with nonselective beta-blockers. Its cardioselective profile and favourable tolerability are particularly useful in patients with coexisting heart failure, coronary disease or respiratory comorbidities." 

Key Takeaway

The ROBUST study highlights that β-blockers remain a cornerstone therapy in HF and AF management in India, with metoprolol emerging as a widely acceptable agent across real-world practice.

Abbreviations

HF- Heart Failure; AF- Atrial Fibrillation; JAPI- Journal of the Association of Physicians of India; HCP- Health-Care Professionals; HFrEF- Heart Failure with Reduced Ejection Fraction