Key result
Long-term beta-blockers after MI reduce major events, yielding ~4% absolute risk reduction in high-risk patients.
Why the study?
Recent meta-analyses show beta-blockers benefit post-MI patients with mildly reduced LVEF but not preserved LVEF, leaving it unknown whether simple clinical risk factors identify patients with greater absolute benefit.
Does long-term beta-blocker therapy reduce the composite of all-cause mortality, MI, unplanned coronary revascularization, ischemic stroke, heart failure, or malignant ventricular arrhythmia in patients with recent MI and LVEF >40%?
RCT (n=5,558)
randomized
Does long-term beta-blocker therapy reduce the composite of all-cause mortality, MI, unplanned coronary revascularization, ischemic stroke, heart failure, or malignant ventricular arrhythmia in patients with recent MI and LVEF >40%?
The absolute benefit of long-term beta-blocker therapy after myocardial infarction in patients with LVEF >40% increases with baseline clinical risk, supporting the use of risk stratification to guide treatment.
Answers are grounded in this paper and cite their sources.
Supports selective post-MI beta-blocker use in higher-risk patients; extends meta-analyses by quantifying greater absolute benefits at elevated baseline risk.
Background Recent meta-analyses show that beta-blockers benefit patients with mildly reduced left ventricular ejection fraction (LVEF) after myocardial infarction (MI), but not those with preserved LVEF. Whether simple clinical risk factors can identify patients who derive greater absolute benefit remains unknown. Purpose To assess whether the clinical effect of long-term beta-blocker therapy after MI differs across baseline risk strata defined by a modified Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention (TRS-2P) Methods This was a substudy of the BETAMI-DANBLOCK trial, which randomized patients with recent MI and LVEF >40% to long-term beta-blocker or no beta-blocker therapy. A modified TRS-2P score (0–8 points) was constructed by excluding current smoking and incorporating mildly reduced LVEF (41–49%). Patients were categorized as low- (0 points), intermediate- (1–2 points), or high-risk (≥3 points). The primary endpoint was a composite of all-cause mortality, MI, unplanned coronary revascularization, ischemic stroke, heart failure, or malignant ventricular arrhythmia. The secondary endpoint was recurrent MI. Within each TRS-2P strata the effect of beta-blocker was estimated using Cox proportional hazard model and Fine-Gray subdistribution hazard model. Three-year absolute risk reduction (ARR) and number needed to treat (NNT) were estimated for each TRS-2P stratum using the total trial hazard ratio (HR) applied to stratum-specific cumulative incidences derived from Kaplan–Meier estimates Results Among the 5,558 patients included in the analysis, 38.4% were low-, 52.8% intermediate-, and 8.8% high-risk. Event rates increased stepwise across risk strata (2.96, 4.58, and 11.05 per 100 person-years, respectively). Relative treatment effects were consistent in low-risk (HR 0.88, 95% CI 0.67-1.13), intermediate-risk (HR 0.81, 95% CI 0.67-0.97), and high-risk patients (HR 0.88, 95% CI 0.63-1.20). Absolute benefit increased with risk strata: 3-year ARR was 1.4% (NNT 72) in low-risk-, 2.1% (NNT 47) in intermediate-risk-, and 3.6% (NNT 28) in high-risk patients. Recurrent MI demonstrated the same pattern, with greater absolute benefit in the higher-risk strata. Conclusions The modified TRS-2P score showed clear prognostic ability, and the absolute benefit of beta-blockers increased with baseline risk despite similar relative effects. These findings support the use of simple clinical risk stratification to guide long-term beta-blocker therapy after MI.
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Caglar et al. (2026) conducted an RCT in Recent myocardial infarction with LVEF >40% (n=5,558). Beta-blocker therapy vs. No beta-blocker therapy was evaluated on Composite of all-cause mortality, MI, unplanned coronary revascularization, ischemic stroke, heart failure, or malignant ventricular arrhythmia. Long-term beta-blocker therapy after MI yielded consistent relative effects across risk strata, but absolute risk reduction at 3 years increased from 1.4% in low-risk to 3.6% in high-risk patients.
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