BETA-BLOCKERS DISCONTINUATION AFTER MYOCARDIAL INFARCTION REFERRING TO EJECTION FRACTION

Abstract

The clinical role of beta-blocker therapy after myocardial infarction (MI) has been debated extensively as the landscape of post-MI management has evolved. Historically, beta-blockers were established as a cornerstone of secondary prevention following landmark randomized controlled trials conducted in the 1980s (Hjalmarson, 1997) that demonstrated significant reductions in all-cause and cardiovascular mortality. However, those foundational studies were conducted before the widespread adoption of primary percutaneous coronary intervention, dual antiplatelet therapy, high-intensity statins, and renin-angiotensin-aldosterone system inhibitors, and they predominantly enrolled patients with reduced left ventricular ejection fraction (LVEF). This review comprehensively synthesizes evidence from contemporary randomized controlled trials including REDUCE-AMI (Yndigegn et al., 2024), ABYSS (Silvain et al., 2024), REBOOT-CNIC (Ibanez et al., 2025), BETAMI-DANBLOCK (Munkhaugen et al., 2025), and landmark individual patient data meta-analysis published between 2024 and 2025, that re-examine the benefits of beta-blockers stratified by LVEF. Findings uniformly demonstrate that among post-MI patients with preserved LVEF (≥50%), long-term beta-blocker therapy does not reduce death or recurrent MI. Patients with mildly reduced LVEF (40-49%) may derive modest benefit, while those with reduced LVEF (<40%) retain a clear and unambiguous indication for beta-blockade. Emerging evidence challenges the appropriateness of routine beta-blocker discontinuation and supports a personalized, ejection fraction-stratified approach. The review also evaluates guideline evolution, mechanisms of action, safety considerations, and directions for future research.