BACKGROUND: Current guideline recommendations for the use of beta-blockers after myocardial infarction without reduced ejection fraction are based on trials conducted before routine reperfusion, invasive care, complete revascularization, and contemporary pharmacologic therapies became standard practice.
METHODS: We conducted an open-label, randomized trial in Spain and Italy to evaluate the effect of beta-blocker therapy, as compared with no beta-blocker therapy, in patients with acute myocardial infarction (with or without ST-segment elevation) and a left ventricular ejection fraction above 40%. The primary outcome was a composite of death from any cause, reinfarction, or hospitalization for heart failure.
RESULTS: In total, 4243 patients were randomly assigned to receive beta-blocker therapy and 4262 to receive no beta-blocker therapy; after exclusions, 8438 patients were included in the main analysis. During a median follow-up of 3.7 years, a primary-outcome event occurred in 316 patients (22.5 events per 1000 patient-years) in the beta-blocker group and in 307 patients (21.7 events per 1000 patient-years) in the no-beta-blocker group (hazard ratio, 1.04; 95% confidence interval [CI], 0.89 to 1.22; P = 0.63). Death from any cause occurred in 161 patients and 153 patients, respectively (11.2 vs. 10.5 events per 1000 patient-years; hazard ratio, 1.06; 95% CI, 0.85 to 1.33); reinfarction in 143 patients and 143 patients (10.2 vs. 10.1 events per 1000 patient-years; hazard ratio, 1.01; 95% CI, 0.80 to 1.27); and hospitalization for heart failure in 39 patients and 44 patients (2.7 vs. 3.0 events per 1000 patient-years; hazard ratio, 0.89; 95% CI, 0.58 to 1.38). No apparent between-group differences in safety outcomes were noted.
CONCLUSIONS: Among patients discharged after invasive care for a myocardial infarction with a left ventricular ejection fraction above 40%, beta-blocker therapy appeared to have no effect on the incidence of death from any cause, reinfarction, or hospitalization for heart failure. (Funded by Centro Nacional de Investigaciones Cardiovasculares Carlos III and others; ClinicalTrials.gov number, NCT03596385; EudraCT number, 2017-002485-40.).
| Discipline Area | Score |
|---|---|
| Hospital Doctor/Hospitalists |  |
| Internal Medicine | |
| Cardiology | |
This trial has important relevance. All of us old heads learned that beta-blockers worked after MI. Many of us are aware that beta-blockers have a lot of side effects, but are worth it in the patients that have heart failure and, we thought, MI. In this very well designed trial of beta-blockers of choice after MI (with very little atenolol, a crappy beta )(0.6%)), there was no difference. This builds very nicely on the results of reduced MI and Capitol RCT trials and should inform future guidelines to reduce recommendations in heart attack patients with a normal ejection fraction. We should find reasons to stop beta-blockers and patients that do not need them or have another compelling reason.
This trial is highly relevant and newsworthy. Beta-blockers are still routinely continued long-term after MI in patients without reduced ejection fraction (EF > 40%). This large pragmatic trial builds on findings from the recently published REDUCE-AMI trial and shows convincingly that in the contemporary era of re-perfusion, statins, and dual antiplatelet therapy, routine beta-blocker therapy has little or no effect in reducing the risks of all-cause death, re-infarction, or hospitalization for heart failure. The findings call for a change in practice and for updated practice guideline recommendations; they suggest clinicians can safely avoid long-term beta-blockers or consider de-prescribing in these patients. The signal of possible harm in women and STEMI subgroups is hypothesis-generating but clinically relevant and is worthwhile evaluating further.
