Stopping Beta-Blockers Years After Heart Attack May Be Safe

STOPPING long-term beta-blocker treatment may be a safe option for some stable patients years after myocardial infarction, according to a pooled analysis of two randomised trials. 

Researchers found that discontinuing beta-blockers was non-inferior to continuing treatment among patients with a previous myocardial infarction, preserved or mildly reduced left ventricular ejection fraction, and no heart failure or other indication for beta-blocker therapy. 

Reassessing Long-Term Beta-Blocker Use 

Beta-blockers have long been a cornerstone of treatment following myocardial infarction. However, improvements in reperfusion, secondary prevention, and cardiovascular care have raised questions about whether lifelong treatment remains necessary for stable patients without heart failure or substantial ventricular dysfunction. 

Researchers pooled individual patient data from the ABYSS and SMART-DECISION randomised trials. The analysis included 6,238 patients who had experienced myocardial infarction more than 6 months previously and had a left ventricular ejection fraction of at least 40%. 

Overall, 3,092 patients were assigned to beta-blocker discontinuation and 3,146 to continued therapy. The median time between myocardial infarction and randomisation was 3.6 years, while median follow-up was 3 years. 

The primary composite outcome included all-cause death, myocardial infarction, stroke, or hospitalisation for cardiovascular reasons. 

Discontinuation Meets Non-Inferiority Threshold 

The primary endpoint occurred in 17.2% of patients who discontinued beta-blockers, compared with 15.9% of those who continued treatment. This corresponded to a hazard ratio of 1.09 and met the study’s predefined criterion for non-inferiority. 

A key secondary endpoint comprising all-cause death, myocardial infarction, or hospitalisation for heart failure occurred in 6.5% and 6.4% of patients, respectively, also meeting the non-inferiority threshold. 

Results were consistent regardless of baseline left ventricular ejection fraction. 

The researchers cautioned that interpretation of the primary endpoint is complicated by its inclusion of cardiovascular hospitalisations, which can be more susceptible to differences between open-label trials than outcomes such as death or myocardial infarction. 

Towards More Individualised Treatment 

The findings suggest that indefinite beta-blocker therapy may not be necessary for every stable patient following myocardial infarction. 

Instead, the authors propose a more individualised, stage-specific approach in patients who have recovered from myocardial infarction, have an ejection fraction of at least 40%, and have no heart failure or another clinical reason to continue treatment. 

The findings do not apply to patients with heart failure, substantially reduced ejection fraction, or another established indication for beta-blockers. 

Reference 

Silvain J, et al. Discontinuation of β-blockers in stable patients with previous myocardial infarction, preserved left ventricular ejection fraction, and no heart failure: a pooled analysis of individual patient data. Lancet. 2026. 

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