Stopping beta-blockers years after MI with preserved LVEF

Design

Individual-patient pooled analysis of two RCTs (ABYSS, SMART-DECISION)

Population

6238 stable patients >6 months post-MI, LVEF ≥40%, no heart failure

Primary outcome

Death, MI, stroke or cardiovascular hospitalisation

Effect

17.2% vs 15.9%; HR 1.09 (95% CI 0.97 to 1.24), non-inferior

This pooled individual-patient analysis combined the ABYSS and SMART-DECISION randomised trials: 6238 stable patients more than six months after myocardial infarction, LVEF 40% or more, no heart failure and no other indication for a beta-blocker. Median time from MI was 3.6 years and follow-up 3.0 years. It was published in The Lancet in August.

Death, MI, stroke or cardiovascular hospitalisation occurred in 17.2% after discontinuation and 15.9% on continuation (HR 1.09, 95% CI 0.97 to 1.24), meeting the non-inferiority margin of 1.25. Death, MI or heart failure hospitalisation occurred in 6.5% versus 6.4% (HR 1.01, 0.83 to 1.23). Results were consistent across LVEF.

Many patients take a beta-blocker for years after MI with no ongoing reason. This supports reviewing that prescription. The authors caution that the primary end point was dominated by hospitalisations, and the point estimate leans slightly towards continuing, so stopping should be a considered decision rather than a blanket rule.

• Identify patients on beta-blockers only because of an MI more than a year ago.
• Confirm LVEF ≥40%, no heart failure, no angina, arrhythmia or hypertension needing it.
• Taper rather than stop abruptly.
• Review symptoms and heart rate after stopping.

Why it matters

It challenges the habit of continuing post-MI beta-blockers indefinitely.

Don't overread it

Non-inferior is not identical: the interval still allows a small rise in hospitalisations after stopping.

The statistics, in plain English

Non-inferiority means stopping was not worse by more than a prespecified margin (25% relative for the primary end point). The HR of 1.09 and its upper limit of 1.24 still allow a small excess of events after stopping, mostly hospitalisations. The death, MI or heart failure end point showed no difference.

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