Discontinuation of Beta-Blocker Therapy after Myocardial Infarction

Clinical Snapshot

Key Findings

• P Value: P = 0.001 for noninferiority

• Effect Size: Hazard ratio 0.80 favouring discontinuation

• Primary Outcome: Composite of death, recurrent MI, or heart failure hospitalisation

• Nnt Or Sensitivity: Number needed to treat approximately 56 patients to prevent one additional event over 4 years

• Confidence Interval: 95% CI 0.57 to 1.13

Clinical Application

Highly feasible - involves medication discontinuation rather than initiation, with appropriate monitoring Relevant to Australian practice; aligns with contemporary post-MI care. May reduce PBS medication costs and patient pill burden while maintaining safety Stable post-MI patients >1 year with LVEF ≥40% and no heart failure currently on beta-blockers

Abstract

BACKGROUND: The role of long-term beta-blocker therapy after a myocardial infarction in patients without left ventricular systolic dysfunction or heart failure is unclear in the era of contemporary coronary-artery reperfusion and secondary prevention interventions. METHODS: We conducted an open-label, randomized, noninferiority trial at 25 centers in South Korea. Patients whose condition remained stable after a myocardial infarction, who had a left ventricular ejection fraction of at least 40% and no heart failure, and who had received beta-blocker therapy for at least 1 year after the myocardial infarction were randomly assigned in a 1:1 ratio to discontinue or to continue beta-blocker therapy. The primary end point was a composite of death from any cause, recurrent myocardial infarction, or hospitalization for heart failure. The prespecified noninferiority margin was an upper limit of the 95% confidence interval for the hazard ratio of 1.4. RESULTS: A total of 2540 patients underwent randomization; 1246 were assigned to beta-blocker discontinuation and 1294 to beta-blocker continuation. The mean age of the patients was 63.2 years, and 12.8% were women. At a median follow-up of 3.1 years (interquartile range, 2.5 to 3.5), a primary end-point event had occurred in 58 patients (4-year Kaplan-Meier estimate, 7.2%) in the discontinuation group and in 74 patients (4-year Kaplan-Meier estimate, 9.0%) in the continuation group (hazard ratio, 0.80; 95% confidence interval, 0.57 to 1.13; P = 0.001 for noninferiority). The incidence of serious adverse events was similar in the two groups. CONCLUSIONS: Among patients who received beta-blocker therapy beyond the first year after a myocardial infarction, discontinuation of beta-blocker therapy was noninferior to continuation with respect to a composite of death from any cause, recurrent myocardial infarction, or hospitalization for heart failure. (Funded by Patient-Centered Clinical Research Coordinating Center in the Ministry of Health and Welfare, South Korea; SMART-DECISION ClinicalTrials.gov number, NCT04769362.).

References

1. 1.Choi, K. H., Kang, D., Kim, W., Doh, J. H., Kim, J., Park, Y. H., Ahn, S. G., Park, J. P., Kim, S. M., Cho, B. R., Nam, C. W., Cho, J. H., Joo, S. J., Suh, J., Jeong, J. O., Jang, W. J., Goh, C. W., Yoon, C. H., Hwang, J. Y., Lim, S. H., Lee, S. R., Shin, E. S., Kim, B. J., Yu, C. W., Her, S. H., Kim, H. K., Park, K. T., Kim, J., Kim, J., Park, T. K., Lee, J. M., Cho, J., Yang, J. H., Song, Y. B., Choi, S. H., Gwon, H. C., Guallar, E., & Hahn, J. Y. (2026). Discontinuation of beta-blocker therapy after myocardial infarction. *New England Journal of Medicine*. https://doi.org/10.1056/NEJMoa2601005