Beta-blockers can be stopped after an uncomplicated MI with preserved ejection fraction

Design

Pooled individual patient data analysis of two randomised non-inferiority trials

Population

6238 stable patients after MI with ejection fraction ≥40% and no heart failure

Primary outcome

Death, MI, stroke or cardiovascular hospitalisation

Effect

17.2% vs 15.9%, HR 1.09 (95% CI 0.97–1.24), non-inferior; death, MI or heart failure admission HR 1.01 (0.83–1.23)

This individual patient data analysis pooled two randomised trials, ABYSS from France and SMART-DECISION from Korea. Together they included 6238 stable patients a median 3.6 years after myocardial infarction, with ejection fraction of 40% or more, no heart failure and no other reason for a beta-blocker. Patients were randomised to stop or continue, and followed for a median of 3 years. It was published at the end of August 2026.

The primary composite of death, myocardial infarction, stroke or cardiovascular hospitalisation occurred in 17.2% after stopping and 15.9% when continuing (HR 1.09), which met the non-inferiority margin. The composite of death, myocardial infarction or heart failure hospitalisation was identical at 6.5% and 6.4%. Results did not vary by ejection fraction.

For the many patients still taking a beta-blocker years after an uncomplicated infarct, often with fatigue, low heart rate or erectile dysfunction, this supports a conversation about stopping. It does not apply to patients with reduced ejection fraction, heart failure, angina or arrhythmia that needs rate control.

• Identify patients on a beta-blocker only because of a past MI
• Confirm ejection fraction is 40% or more and there is no heart failure, angina or arrhythmia indication
• Ask about side effects such as fatigue, bradycardia or erectile dysfunction
• Taper rather than stop abruptly, and check blood pressure and symptoms afterwards
• Keep beta-blockers where there is any other indication

Why it matters

Years of beta-blocker therapy after an uncomplicated infarct may be adding side effects without adding protection.

Don't overread it

Non-inferiority on a 25% margin does not show stopping is harmless; a small increase in hospitalisations cannot be excluded.

The statistics, in plain English

HR 1.09 (95% CI 0.97–1.24) means slightly more events after stopping, but the upper limit stays under the pre-set non-inferiority margin of 1.25. That margin allows up to a quarter more events, which some would find generous. The secondary composite of harder outcomes, HR 1.01 (0.83–1.23), is more reassuring. The authors note the primary end point was driven by hospitalisations and varied between the two trials.

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