CLINICAL QUESTION: Do beta-blockers still reduce mortality after acute myocardial infarction (MI) in the modern era of faster and better reperfusion strategies?
BACKGROUND: Beta-blockers have historically been a cornerstone of post-MI management. However, in the era of earlier detection of acute MI with high-sensitivity troponin, superior reperfusion strategies, newer anti-thrombotic agents, and renin-angiotensin-aldosterone system (RAAS) blockade agents, there is less post-MI myocardial dysfunction. It is not certain that beta-blockers still impart significant mortality reduction in this context.
STUDY DESIGN: Prospective, registry-based, randomized, open-label, clinical trial
SETTING: The majority of participants were from Sweden’s SWEDEHEART registry
SYNOPSIS: More than 50% of 5,020 patients from a national patient registry with acute MI, proven obstructive coronary disease on cardiac angiography, and left ventricular ejection fraction were randomized to receive beta-blocker treatment versus no beta-blocker. The median follow-up period was 3.5 years. Over that time, there was no significant difference between study groups with respect to the annual event rate of death from any cause or recurrent MI. However, a notable limitation is the open-label design. Additionally, as this was a pragmatic trial, there was a nearly 14% rate of crossover between treatment groups despite efforts to mitigate this.
BOTTOM LINE: It is no longer clear that beta-blockers reduce mortality after MI in the era of modern reperfusion techniques and anti-thrombotic agents.
CITATION: Yndigegn T, et al. Beta-blockers after myocardial infarction and preserved ejection fraction. N Engl J Med. 2024;390(15):1372-1381. doi: 10.1056/NEJMoa2401479
Dr. Hilbert
Dr. Hilbert is a hospitalist in the department of hospital medicine at Duke Regional Hospital and a medical instructor at Duke University School of Medicine, both in Durham, N.C.