Key result
Routine beta-blocker discontinuation is supported for post-ACS patients with LVEF ≥50% based on shared decision-making.
Why the study?
In the contemporary era of early mechanical reperfusion and modern secondary prevention, the benefit of beta-blockers after ACS without reduced LVEF has been questioned.
Does beta-blocker discontinuation increase the risk of major adverse cardiovascular events in post-ACS patients without reduced LVEF?
Does beta-blocker discontinuation increase the risk of major adverse cardiovascular events in post-ACS patients without reduced LVEF?
Routine beta-blocker therapy may be safely discontinued in post-ACS patients with preserved LVEF (≥50%), emphasizing individualized shared decision-making.
Supports considering beta-blocker discontinuation post-ACS with LVEF ≥50%; leaves open confirmation by randomized trials.
INTRODUCTION: Beta-blocker therapy reduced mortality and cardiovascular events following acute coronary syndromes (ACS) in the pre-reperfusion era. In the contemporary era of early mechanical reperfusion and modern secondary prevention, the benefit of beta-blockers after ACS without reduced left ventricular ejection fraction (LVEF) has been questioned. This review was based on PubMed database searches from inception to January 2025. AREAS COVERED: The recent REDUCE-AMI and ABYSS trials were the first adequately powered contemporary randomized trials evaluating beta-blockers after ACS without reduced LVEF. Contemporary observational evidence is also discussed. Implications for different LVEF categories (41-49% versus ≥ 50%), ACS subtypes, beta-blocker therapy duration, optimal dose, and interaction with other secondary prevention therapies are addressed. EXPERT OPINION: We estimate that there is sufficient evidence to abandon routine beta-blocker prescription in post-ACS patients with preserved LVEF ≥ 50%. Beta-blocker prescription should be individualized with shared decision-making, balancing the risk of cardiovascular event against potential benefits of deprescription. Factors favoring beta-blocker discontinuation include adverse effects, polypharmacy, >1-3 years of stability post-ACS, and specific comorbidities (e.g. heart failure with preserved LVEF). Factors favoring beta-blocker prescription/continuation (besides established indications such as LVEF ≤ 40%, arrhythmias, angina, and refractory hypertension) include good tolerance, LVEF 41-49%, and non-adherence to other secondary prevention therapies.
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Johner et al. (2025) conducted a review in Acute coronary syndromes (ACS) without reduced LVEF. Beta-blocker discontinuation vs. Beta-blocker continuation was evaluated on Major adverse cardiovascular events. Routine beta-blocker discontinuation is supported for post-ACS patients with preserved LVEF ≥50%, with prescription individualized based on shared decision-making and clinical factors.
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