August 1, 2026The Lancet
Discontinuation of β-blockers in stable patients with previous myocardial infarction, preserved left ventricular ejection fraction, and no heart failure: a pooled analysis of individual patient data
Johanne SilvainJohanne SilvainKi Hong ChoiVictorien MonguillonDanbee KangGuillaume CaylaWeon KimÉmile FerrariYoung Bin SongGrégoire RangéÉtienne PuymiratJoon‐Hyung DohNicolas DelarcheJu Han KimPaul GuedeneyYong Hwan ParkAbdourahmane DialloSung Gyun AhnEric VicautGilles MontalescotJoo-Yong HahnJoo-Yong HahnWissam Abi-KhalilJérémie AbtanSung Gyun AhnFranck AlbertVincent AlgalarrondoNicolas AmabileAimé AmonchotYann AncédyStéphane AndrieuDavid AouateAnnick Astie-DardaillonN. BaronOlivier BarthélémyJules BateauMarc Ornel Batonga YangaChristophe BautersSandrine BayleFlorence BeauvaisThomas BénardR. BensaidFarzin BeyguiLoic BiereMathieu BignonKatrien BlanchartE. BlicqFranck BoccaraN BouziriNassim BraikFrançois BresolesClément BrietLéa CacoubAudrey CailliauAudrey CamarzanaJulia CaudronChristophe CaussinGuillaume CaylaAlexandre CeccaldiC. CharbonnelMarion Chauvet-DroitPaul-Matthieu ChiaroniByung Ryul ChoJang Hyun ChoJuhee ChoKi Hong ChoiSeung-Hyuk ChoiR. ChoussatLuc ChristiaensAndréa CianciBernard CitronR. CohenAlain Cohen-SolalJean‐Philippe ColletNicolas CombaretR. Convers-DomartLuc CornilletYves CottinArthur DarmonMadalina DasoveanuAurélien de PommereauNicolas DelarcheStéphane DelepineCédric DelhayePascal DelsartThibault DemicheliChristelle DiakovAlain DibiéJean-Guillaume DillingerFatima DjelailiJoon‐Hyung DohBenjamin DubandGrégory DucrocqTéodora DutoiuStephane EderhySimon ElhadadDamien FardAntoine FayolLaurent FeldmanArnaud Ferrante
Key result
Discontinuing β-blockers is non-inferior to continuation for major cardiovascular events in stable post-MI patients.
- HR 1.09
- 95% CI 0.97-1.24
- n=6,238
Why the study?
Whether β-blockers can be safely discontinued in stable post-myocardial infarction patients without heart failure or an ongoing indication remains uncertain.
Does β-blocker discontinuation safely maintain cardiovascular outcomes compared to continuation in stable patients with previous myocardial infarction, LVEF ≥40%, and no heart failure?
Key Points
- To assess the non-inferiority of discontinuing versus continuing β-blocker therapy in stable patients with a prior myocardial infarction, preserved left ventricular ejection fraction (≥40%), and no heart failure.
- Pooled individual patient data from the ABYSS and SMART-DECISION randomized trials, including 6,238 stable patients at least 6 months post-myocardial infarction with LVEF ≥40% and no heart failure.
- Randomly assigned 3,092 patients to β-blocker discontinuation and 3,146 to continuation, with a median follow-up of 3.0 years (IQR 2.3–3.8).
- Evaluated outcomes using a one-stage mixed-effects Cox proportional hazards model with a non-inferiority margin of 1.25 for the primary composite endpoint (all-cause death, myocardial infarction, stroke, or cardiovascular hospitalization).
- The primary composite endpoint occurred in 17.2% (532/3,092) of patients in the discontinuation group versus 15.9% (500/3,146) in the continuation group (HR 1.09, 95% CI 0.97–1.24), meeting the pre-specified 1.25 non-inferiority margin.
- Discontinuation also met the non-inferiority criteria (margin 1.40) for the key secondary endpoint of all-cause death, myocardial infarction, or hospitalization for heart failure.
Study Design
Type
Meta-Analysis (n=6,238)
Multicenter
Yes
Structured PICO
Does β-blocker discontinuation safely maintain cardiovascular outcomes compared to continuation in stable patients with previous myocardial infarction, LVEF ≥40%, and no heart failure?
P
Population
6,238 stable patients >6 months post-myocardial infarction with LVEF ≥40% and no heart failure, followed for a median of 3.0 years.
I
Intervention
β-blocker discontinuation
C
Comparator
β-blocker continuation
O
Outcome
Composite of all-cause death, myocardial infarction, stroke, or hospitalisation for cardiovascular reasonscomposite
Main Result
Hazard Ratio: 1.09 (95% CI 0.97–1.24)
Absolute Event Rate: 17.2% vs 15.9%
In stable patients with a history of myocardial infarction, preserved ejection fraction, and no heart failure, discontinuing β-blocker therapy was non-inferior to continuation for cardiovascular outcomes.
Limitations
- Interpretation of the primary endpoint is limited by its hospitalisation-heavy and trial-dependent composition.
- Interpretation of the primary endpoint is limited by its hospitalisation-heavy and trial-dependent composition
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Taken together, the available evidence supports a stage-specific and individualised approach to β-blocker therapy after myocardial infarction. Late discontinuation after initial treatment in the early post-acute phase can be considered with appropriate clinical monitoring.”
“The apparent controversy may be less pronounced than it seems. First, the REDUCE-AMI trial specifically included only patients with a left ventricular EF of 50% or higher, whereas the ABYSS should be viewed separately, as it investigated patients a median of more than two years after their index MI - rather than those in the acute or early postinfarction phase.”
BIBorja IbanezCardiologist, Centro Nacional de Investigaciones Cardiovasculares, Madrid
“Given the open-label nature of both trials and the trial-dependent ascertainment of cardiovascular hospitalisation, the harder secondary composite is arguably the most reassuring and clinically interpretable result of the pooled analysis.”
Implication
May warrant β-blocker deprescribing in stable post-MI patients with preserved LVEF; challenges routine long-term continuation.
Abstract
BACKGROUND: Many stable patients with chronic coronary syndrome continue β-blocker therapy for years after a myocardial infarction, despite having no clear ongoing indication. Whether β-blockers can be safely discontinued in such patients remains uncertain. The objective of this analysis was to assess the non-inferiority of β-blocker discontinuation versus continuation in patients with previous myocardial infarction and no remaining indication. METHODS: We performed a pooled analysis of individual patient data from the ABYSS and SMART-DECISION randomised trials in stable patients over 6 months after a myocardial infarction with a left ventricular ejection fraction of ≥40% and no heart failure. Non-inferiority was assessed for the composite primary endpoint of all-cause death, myocardial infarction, stroke, or hospitalisation for cardiovascular reasons, and for the key secondary endpoint of all-cause death, myocardial infarction, or hospitalisation for heart failure. Analyses used a one-stage mixed-effects Cox proportional hazards model including trial as a random effect with margins of 1·25 for the primary endpoint and 1·40 for the key secondary endpoint. The review protocol was registered with PROSPERO, number CRD420261299839. FINDINGS: Among 6238 patients (3698 from ABYSS and 2540 from SMART-DECISION), 3092 were assigned to β-blocker discontinuation and 3146 to continuation. Median time from index myocardial infarction to randomisation was 3·6 years (IQR 1·6-7·5) and median follow-up was 3·0 years (2·3-3·8). The primary endpoint occurred in 532 (17·2%) of 3092 patients in the β-blocker discontinuation group and 500 (15·9%) of 3146 in the continuation group (hazard ratio 1·09 [95% CI 0·97-1·24]; p INTERPRETATION: In stable patients with previous myocardial infarction, left ventricular ejection fraction ≥40%, no heart failure, and no other indication for β-blocker therapy, discontinuation met the non-inferiority criteria for the primary and key secondary endpoints. Interpretation of the primary endpoint is limited by its hospitalisation-heavy and trial-dependent composition.
Discussion
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Cite This Study
Silvain et al. (2026) conducted a meta-analysis in previous myocardial infarction (n=6,238). β-blocker discontinuation vs. β-blocker continuation was evaluated on all-cause death, myocardial infarction, stroke, or hospitalisation for cardiovascular reasons (HR 1.09, 95% CI 0.97-1.24). Discontinuation of β-blockers was non-inferior to continuation for death, MI, stroke, or cardiovascular hospitalization in stable post-MI patients (HR 1.09; 95% CI 0.97-1.24).