Key result
Routine beta-blockers show no benefit over placebo for MACE after MI with preserved LVEF.
Why the study?
Recent randomized controlled trials in post-MI patients without significantly impaired LVEF have yielded conflicting results regarding beta-blocker therapy.
Does long-term oral beta-blocker therapy reduce major adverse cardiovascular events in post-myocardial infarction patients with LVEF ≥40%?
Meta-Analysis (n=23,468)
randomized
Yes
Does long-term oral beta-blocker therapy reduce major adverse cardiovascular events in post-myocardial infarction patients with LVEF ≥40%?
Relative Risk: 0.96 (95% CI 0.87–1.05)
p-value: p=0.203
Routine long-term oral beta-blocker therapy does not reduce major adverse cardiovascular events in post-myocardial infarction patients with preserved ejection fraction (LVEF ≥40%), challenging universal prescription practices.
Questions routine beta-blocker use post-MI without reduced LVEF; challenges consensus from older reduced-LVEF trials.
Background and Aims Beta-blocker (BB) therapy after myocardial infarction (MI) in patients with reduced left ventricular ejection fraction (LVEF) is well established. However, recent randomised controlled trials (RCTs) in post-MI patients without significantly impaired LVEF have yielded conflicting results. This meta-analysis aimed to synthesise pooled evidence from high-quality RCTs to clarify the role of BB therapy in this population. Methods A systematic literature search was conducted across major scientific databases until 1 April 2026 for RCTs comparing long-term oral BB therapy against no BB in post-MI patients with LVEF ≥40%. The primary outcome was major adverse cardiovascular events (MACE), defined as a composite of all-cause mortality, MI or acute coronary syndrome, or hospitalisation for heart failure. A random-effects model using the Mantel-Haenszel method was used to pool risk ratios (RR) and 95% confidence intervals (CI), with heterogeneity assessed using the I² statistic. Results Six RCTs (CAPITAL-RCT, REDUCE-AMI, ABYSS, REBOOT-CNIC, BETAMI-DANBLOCK, and SMART-DECISION) were included, encompassing 11,698 patients in the BB group and 11,770 in the no-BB group. BB therapy was not associated with a significant reduction in MACE compared to no BB therapy (RR 0.96, 95% CI 0.87–1.05; I² = 31.0%; p = 0.203), with a prediction interval of 0.78–1.18. Conclusion This updated meta-analysis, incorporating the recently published SMART-DECISION trial, found that routine BB therapy in post-MI patients without significantly impaired LVEF does not reduce MACE. These findings challenge universal BB prescription in this population, where historical benefits may be attenuated by contemporary secondary prevention strategies.Figure 1.Pooled analysis of beta-blocker versus no beta-blocker therapy for major adverse cardiovascular events in post-myocardial infarction patients without reduced ejection fraction, incorporating six randomised controlled trials including the updated SMART-DECISION trial (2026).
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Arba et al. (2026) conducted a meta-analysis in Myocardial infarction without significantly impaired LVEF (n=23,468). Beta-blocker therapy vs. No beta-blocker was evaluated on Major adverse cardiovascular events (MACE), composite of all-cause mortality, MI or acute coronary syndrome, or hospitalisation for heart failure (RR 0.96, 95% CI 0.87-1.05, p=0.203). Routine beta-blocker therapy did not reduce major adverse cardiovascular events compared to no beta-blocker in post-MI patients with LVEF ≥40% (RR 0.96; 95% CI 0.87-1.05; p=0.203).
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