Key result
Weighting the BETAMI and DANBLOCK trial populations to match the real-world NORMI cohort showed consistent beta-blocker treatment effects, despite lower baseline risks in the trials (7.7% vs 12.0%).
Why the study?
This study evaluated the representativeness of the combined BETAMI-DANBLOCK trial in patients with myocardial infarction, no heart failure, and LVEF >= 40%.
Are the treatment effects of beta-blockers observed in the BETAMI-DANBLOCK trials generalizable to a real-world nationwide myocardial infarction population?
Observational (n=26,378)
Yes
Are the treatment effects of beta-blockers observed in the BETAMI-DANBLOCK trials generalizable to a real-world nationwide myocardial infarction population?
Despite trial participants being younger and having fewer comorbidities than a real-world nationwide MI cohort, the efficacy of beta-blockers in patients with LVEF ≥40% remains consistent and generalizable.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Evidence supporting beta-blocker therapy after MI was established before the introduction of modern coronary reperfusion therapy and secondary prevention strategies. And while beta-blockers are strongly recommended for patients with MI and reduced LVEF, their role in MI patients with preserved or mildly reduced LVEF (≥40%) without heart failure is less certain.”
“Long-term beta-blocker therapy reduced the composite of all-cause mortality and major adverse cardiovascular events in this patient population, with a notable decrease in the incidence of new MI. Our findings suggest that, despite advances in contemporary MI treatment, the beneficial effects of beta-blocker therapy remain clinically relevant, even in patients without reduced LVEF or heart failure. However, the results must be considered alongside other recent and ongoing trials of beta-blocker therapy after MI to determine their implications for clinical practice.”
“When we look at [our trial], we could also see a trend, not a significant [finding], where patients with low ejection fraction seemed to have a benefit.”
Supports transportability of BETAMI-DANBLOCK effects to real-world MI cohorts; extends trial evidence yet leaves practice implications open pending further RCTs.
BACKGROUND AND AIMS: In patients with myocardial infarction (MI), no heart failure, and left ventricular ejection fraction (LVEF) ≥ 40%, the combined BETAMI-DANBLOCK trial showed that beta-blockers reduced the risk of all-cause mortality or major adverse cardiovascular events. This study evaluated the representativeness of the trial. METHODS: Participants in BETAMI (n = 2867) and DANBLOCK (n = 2707) were compared with a cohort of revascularized MI patients with LVEF ≥40%, and no heart failure from the Norwegian Myocardial Infarction Registry (the NORMI cohort)(n = 20 804). Baseline characteristics were evaluated, and absolute risks of all-cause mortality and/or MI were estimated. A transportability analysis was conducted by weighting the BETAMI-DANBLOCK population according to the NORMI cohort. RESULTS: Median age was 66 years (interquartile range [IQR]: 57-74) in the NORMI cohort and 63 years (IQR: 55-70) in BETAMI and DANBLOCK. Patients in the NORMI cohort had a higher prevalence of diabetes, previous coronary artery disease, and LVEF 40-49%, compared with trial participants. At 3-year follow-up, the absolute risk of all-cause mortality or MI was 12.0% in the NORMI cohort, 7.7% in BETAMI, and 7.8% in DANBLOCK. Corresponding risks of MI were 6.3%, 5.6%, and 4.3%, respectively. The treatment effects of beta-blockers were similar when the trial population was weighted according to the characteristics of the NORMI cohort. CONCLUSIONS: Compared with the NORMI cohort, participants in BETAMI and DANBLOCK were younger, had a lower proportion of certain comorbidities, and experienced a lower risk of all-cause mortality and MI. Despite these differences, the effect of beta-blockers remained consistent when the trial population was weighted according to the NORMI cohort.
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Kristensen et al. (2026) conducted an observational in Myocardial infarction (n=26,378). Beta-blockers vs. NORMI cohort (real-world registry) was evaluated on All-cause mortality or MI. Weighting the BETAMI and DANBLOCK trial populations to match the real-world NORMI cohort showed consistent beta-blocker treatment effects, despite lower baseline risks in the trials (7.7% vs 12.0%).
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