Beta-Blocker Therapy After Acute Myocardial Infarction

Historically, beta-blockers have long represented a cornerstone of secondary prevention after acute myocardial infarction (AMI). However, the transition to the modern era of early reperfusion and potent pharmacotherapy has questioned their universal efficacy, particularly in patients without post-AMI left ventricular dysfunction. This review critically analyzes current evidence on the role, timing, and optimal duration of beta-blocker therapy after AMI, with a focus on the impact of left ventricular ejection fraction (LVEF). Relevant literature was identified through searches of PubMed and Web of Science, with particular emphasis on randomized trials and meta-analyses investigating beta-blocker efficacy and safety post-AMI. The search strategy focused on the interaction between LVEF categories and clinical outcomes. Data from historical cohorts and modern trials were synthesized to evaluate the optimal timing and duration of therapy according to the LVEF phenotype. While the survival benefit of beta-blockers remains undisputed for patients with LVEF < 40%, contemporary evidence demonstrates a lack of prognostic advantage for routine beta-blockade in patients with preserved LVEF (i.e., ≥50%). Crucially, recent meta-analyses reveal that patients with LVEF (40–49%) may derive significant benefit from long-term therapy with beta-blockers. Regarding duration, evidence on deprescription remains conflicting. Although earlier data highlighted risks of hemodynamic rebound upon withdrawal, recent trials demonstrate that discontinuing beta-blocker therapy in the chronic phase of AMI may be a safe strategy. Long-term beta-blocker therapy after AMI is supported by robust evidence in patients with LVEF < 40%, whereas emerging but less definitive evidence suggests a potential benefit in those with LVEF 40–49%. Conversely, contemporary randomized trials do not support routine beta-blockade for patients with preserved LVEF (≥50%) in the absence of other clinical indications. As such, further studies are needed to refine patient selection and inform future guideline recommendations across the whole LVEF spectrum.