Abstract Body (Do not enter title and authors here): Background: Patients with heart failure with reduced ejection fraction (HFrEF) and end-stage renal disease (ESRD) represent a high-risk population in whom optimal beta-blocker selection remains unclear. While metoprolol succinate is commonly used, bisoprolol offers theoretical pharmacologic advantages including greater beta-1 selectivity and renal clearance properties, potentially influencing outcomes in ESRD patients undergoing dialysis. Unfortunateley real world head to head comparison data are very limited.

Research Question: Among patients with HFrEF and ESRD, does bisoprolol use confer improved 1-year cardiovascular outcomes compared with metoprolol succinate?

Methods: We conducted a retrospective cohort study using the TriNetX US Collaborative Network, identifying adults ≥18 years with HFrEF and ESRD who initiated either bisoprolol(n=525) or metoprolol succinate (n=918) between January 2004 and December 2023. Patients with prior exposure to both agents were excluded. After one-to-one propensity score matching on demographics, comorbidities, and cardiovascular medications, 133 patients per group were analyzed. Primary outcomes included all-cause mortality and major adverse cardiovascular events (MACE: myocardial infarction, stroke, or death). Secondary outcomes included 4-point MACE (MACE + angina), hospitalization, and kidney transplantation. Risk ratios, hazard ratios (HR), and 95% confidence intervals (CI) were computed.

Results: Bisoprolol was associated with significantly lower 1-year all-cause mortality compared with metoprolol succinate (17.1% vs 29.7%; HR 0.58, 95% CI 0.34–0.99, p=0.023). MACE rates were lower with bisoprolol (19.7% vs 29.9%; HR 0.70, 95% CI 0.36–1.35), although not statistically significant. Similarly, 4-point MACE occurred less frequently with bisoprolol (16.4% vs 27.9%; HR 0.63, 95% CI 0.30–1.32). No difference was observed in 1-year hospitalization rates (42.9% vs 42.1%; HR 1.02, 95% CI 0.70–1.47).

Conclusions: In this real-world, propensity-matched cohort of patients with HFrEF and ESRD, bisoprolol was associated with lower 1-year mortality compared with metoprolol succinate, but had comparable MACE and Hospitalization rates. These findings suggest bisoprolol may offer a survival benefit in this high-risk population and merit further prospective evaluation.