What happened
Discontinuing beta-blockers beyond one year post-MI shows noninferiority to continuation for major events.
Why the trial, key points, tables, limitations, PICO, abstract, media & sources
Why the trial?
Does discontinuation of beta-blocker therapy prevent a composite of death from any cause, recurrent myocardial infarction, or hospitalization for heart failure in patients who received beta-blocker therapy beyond the first year after a myocardial infarction?
RCT
Does discontinuation of beta-blocker therapy prevent a composite of death from any cause, recurrent myocardial infarction, or hospitalization for heart failure in patients who received beta-blocker therapy beyond the first year after a myocardial infarction?
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Expert reaction
NEJM · ACC Annual Scientific Session 2025
2 experts have reacted so far. We show the split once 3 have.
Expert labels are toward SMART-DECISION's result, from named public quotes (n=2). As of Apr 8, 2026.
Captured external expert commentary on this trial, strongest first. Original sources are linked where available.
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.
“In appropriately selected patients who survived a heart attack and do not have [HF] or left ventricular systolic dysfunction, routine continuation of beta-blockers indefinitely may not be necessary. In practice, for stable patients who are several years out from a heart attack, discontinuation can be considered through shared decision-making and with monitoring of blood pressure and heart rate. For patients with beta-blocker-related side effects – fatigue, dizziness, bradycardia, hypotension – the case for discontinuation is even stronger.”
Discontinuation of beta-blocker therapy beyond one year post-myocardial infarction is noninferior to continuation for preventing major adverse cardiovascular events.
BACKGROUND: The role of long-term beta-blocker therapy after a myocardial infarction in patients without left ventricular systolic dysfunction or heart failure is unclear in the era of contemporary coronary-artery reperfusion and secondary prevention interventions. METHODS: We conducted an open-label, randomized, noninferiority trial at 25 centers in South Korea. Patients whose condition remained stable after a myocardial infarction, who had a left ventricular ejection fraction of at least 40% and no heart failure, and who had received beta-blocker therapy for at least 1 year after the myocardial infarction were randomly assigned in a 1:1 ratio to discontinue or to continue beta-blocker therapy. The primary end point was a composite of death from any cause, recurrent myocardial infarction, or hospitalization for heart failure. The prespecified noninferiority margin was an upper limit of the 95% confidence interval for the hazard ratio of 1.4. RESULTS: A total of 2540 patients underwent randomization; 1246 were assigned to beta-blocker discontinuation and 1294 to beta-blocker continuation. The mean age of the patients was 63.2 years, and 12.8% were women. At a median follow-up of 3.1 years (interquartile range, 2.5 to 3.5), a primary end-point event had occurred in 58 patients (4-year Kaplan-Meier estimate, 7.2%) in the discontinuation group and in 74 patients (4-year Kaplan-Meier estimate, 9.0%) in the continuation group (hazard ratio, 0.80; 95% confidence interval, 0.57 to 1.13; P = 0.001 for noninferiority). The incidence of serious adverse events was similar in the two groups. CONCLUSIONS: Among patients who received beta-blocker therapy beyond the first year after a myocardial infarction, discontinuation of beta-blocker therapy was noninferior to continuation with respect to a composite of death from any cause, recurrent myocardial infarction, or hospitalization for heart failure. (Funded by Patient-Centered Clinical Research Coordinating Center in the Ministry of Health and Welfare, South Korea; SMART-DECISION ClinicalTrials.gov number, NCT04769362.).
Choi et al. (2026) conducted an RCT in Myocardial infarction. Discontinuation of beta-blocker therapy vs. Continuation of beta-blocker therapy was evaluated on Composite of death from any cause, recurrent myocardial infarction, or hospitalization for heart failure. Discontinuation of beta-blocker therapy beyond the first year after a myocardial infarction was noninferior to continuation for a composite of death, recurrent MI, or heart failure hospitalization.
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