Heart Failure in Women: Updates from the National Consensus on Bisoprolol

Heart failure (HF) remains a significant cardiovascular public health concern in India, affecting an estimated 1.3 to 22.7 million people. The annual incidence ranges from 0.5 to 1.8 million, with extrapolated data suggesting a national prevalence of approximately 1%, corresponding to roughly 8–10 million cases, and 0.1 to 0.16 million HF-related deaths annually. (1)

Age-Driven Rise in HF Among Women: Women account for nearly 50% of all HF cases in India. While younger men are more frequently diagnosed, HF incidence in women increases more sharply with age. (2) Between 65 and 85 years, the incidence rate triples in women compared to doubling in men, and by age 80, the gender gap narrows. Beyond 80, HF prevalence is higher in women. This trajectory highlights the need for age- and gender-tailored cardiovascular care in Indian women. (3)

Gender Differences in Heart Failure Clinical Spectrum: Indian women with HF often present at an older age, with more symptoms but fewer ischemic causes than men. Women are more likely to develop HF with preserved ejection fraction (HFpEF), often due to microvascular dysfunction, unlike the macrovascular origins typically seen in men with HFrEF. Distinct cardiovascular traits such as smaller LV size, lower stroke volume, higher resting heart rate, and reduced vasoconstriction in women further contribute to sex-specific disease patterns and outcomes. (2,3)

Figure: Sex Differences in Heart Failure: Summary of Differences Between Men and Women. Adapted from Shorthill S, et al. The influence of estrogen on cardiac function in women. Can J Physiol Pharmacol. 2024;102. doi:10.1139/cjpp-2023-0412.

Women Remain Underrepresented in HF Trials: Despite guideline recommendations for 30% female representation in HF trials, women remain consistently underrepresented, limiting the generalizability of evidence to real-world female populations. This is particularly concerning in HFpEF, where women are the predominant demographic. The Indian consensus flags this as a critical evidence gap, emphasizing the need for more inclusive research and sex-specific treatment strategies. (3)

Bisoprolol in CV Care Continuum: Spotlight on Indian National Consensus 2025 (1)

Recently, the National Consensus Statement on the Role of Bisoprolol across the Cardiovascular Continuum was published (JAPI May 2025 Issue), offering India-specific guidance on the clinical use of bisoprolol across various cardiovascular conditions, including heart failure, with a particular emphasis on women.

The consensus reaffirmed bisoprolol as a key β1-selective β-blocker in heart failure care, with proven benefits across heart failure outcomes, including survival and event reduction, and suitability for patients with common comorbidities. It was developed by Indian cardiologists, physicians, and a multispecialty panel including 127 doctors through a rigorous review of clinical trials, real-world data, clinical guidelines, and gender-specific considerations.

The consensus outlines the following key recommendations and clinical considerations for the use of bisoprolol in heart failure:

• Bisoprolol was the first β-blocker shown to improve heart failure outcomes and remains central to current treatment guidelines.
• Bisoprolol is a key pillar in the management of HFrEF, in alignment with guideline-directed medical therapy (GDMT) and real-world practice in India.
• It has demonstrated significant reductions in mortality and cardiovascular events in HFrEF, with particularly favorable outcomes observed in women.
• It significantly reduces the risk of sudden cardiac death (SCD) in patients with HfrEF, with a very rate as 46% in CIBIS III.
• In HFpEF, bisoprolol remains relevant due to its common use in managing comorbidities such as hypertension, coronary artery disease, atrial fibrillation, ventricular arrhythmias, angina, and recent myocardial infarction.
• With the increasing adoption of ARNI-based therapy in HFrEF, bisoprolol is considered a suitable β-blocker to be used in combination, offering complementary benefits.
• The consensus highlights bisoprolol, with its high β1-selectivity, balanced renal and hepatic clearance, low dialyzability, and minimal central nervous system penetration, as contributing to good long-term tolerability. Bisoprolol’s minimal effect on lipid and glucose metabolism makes it suitable for women with diabetes or metabolic syndrome. At the same time, its limited impact on lung function is beneficial in those with asthma or COPD.

Bisoprolol has shown safety and efficacy across the entire spectrum of CKD, including patients not on dialysis. Its minimal dialyzability ensures that BP remains stable during dialysis, reducing CV adverse events compared to other BBs. These advantages make bisoprolol the preferred β-blocker among nephrologists.

This underutilization is attributed to factors such as atypical symptom presentation, delayed diagnosis, and concerns over bradycardia or hypotension. The expert panel calls for the proactive application of guideline-directed therapies, including bisoprolol in eligible women, to help bridge this treatment gap and optimize cardiovascular outcomes in women.

Abbreviations: HF – Heart Failure, HFrEF – Heart Failure with Reduced Ejection Fraction, HFpEF – Heart Failure with Preserved Ejection Fraction, CV – Cardiovascular, CRT – Cardiac Resynchronization Therapy, CKD – Chronic Kidney Disease, CAD – Coronary Artery Disease, AF – Atrial Fibrillation, VA – Ventricular Arrhythmias, MI – Myocardial Infarction, SCD – Sudden Cardiac Death, ARNI – Angiotensin Receptor–Neprilysin Inhibitor, GDMT – Guideline-Directed Medical Therapy, JAPI – Journal of the Association of Physicians of India, BB – Beta-blocker (β-blocker)

References:

1.Chopra HK, Sethi KK, Nair T. et al. National Consensus Statement on Role of Bisoprolol across Cardiovascular Continuum: Special Focus on Women. J Assoc Physicians India 2025;73(5):e16–e33.

2. Yerram, Sreekanth1; Maddury, Jyotsna2. A review of heart failure in women - the Indian perspective. Heart Failure Journal of India 1(1):p 26-30, January-April 2023.| DOI: 10.4103/HFJI.HFJI_6_23

3. Maddury J. Heart failure in women. Indian J Cardiovasc Dis Women 2022;7:162-74.