SMART-DECISION
Discontinuation of Beta-Blocker Therapy in Stabilized Patients After Acute Myocardial Infarction
Published in NEJM
Key Result
Discontinuing beta-blockers in stable post-MI patients without HF or LV dysfunction was noninferior to continuing treatment — first RCT evidence supporting beta-blocker de-escalation in this population.
What did this trial find?
SMART-DECISION was the first RCT to demonstrate that discontinuing beta-blockers in stable post-MI patients without heart failure or LV dysfunction was noninferior to continuing treatment. At median follow-up of 3.1 years, the composite of death, MI, or HF hospitalization occurred in 7.2% of the discontinuation group vs 9.0% of the continuation group (HR 0.80; 95% CI 0.57-1.13; p=0.001 for noninferiority). The results contrast with the earlier ABYSS trial, which failed to meet noninferiority for beta-blocker interruption, generating meaningful debate about the role of long-term beta-blockers post-MI.
Why does this trial matter?
Moderate controversy. SMART-DECISION directly contradicts the earlier ABYSS trial on beta-blocker discontinuation, creating genuine interpretive tension. The lead investigator himself acknowledges the results are 'not definitive,' and there is meaningful debate about whether these findings should change practice. However, the available quote supply is limited — only two named experts are quoted in the source material (Hahn and Gulati), and no editorial or formal discussant commentary was captured.
Study Design
Randomized, controlled, noninferiority trial (N=2,540, median follow-up 3.5 years)
Clinical Implications
Challenges the paradigm of indefinite beta-blocker use post-MI in stable patients. May influence future guideline updates toward reassessing long-term beta-blocker necessity, particularly in patients >4 years from their event.
Abstract
SMART-DECISION was the first RCT demonstrating the safety of discontinuing beta-blockers in stable post-MI patients without heart failure or LV dysfunction. The trial randomized 2,540 patients 1:1 to continue or discontinue beta-blocker therapy, with median follow-up of 3.5 years. The three-point composite of death, MI, or hospitalization for heart failure met noninferiority when beta-blockers were stopped more than 4.7 years after the index MI.