No benefit of beta-blockers post-MI without LV dysfunction

After MI with LVEF >40%, routine beta-blockers did not lower death, reinfarction, or heart-failure hospitalization.Pragmatic open-label randomized trial with blinded adjudication (PROBE); Level 1b (2011 OCEBM).

Background

In the reperfusion era with PCI, statins, and dual antiplatelet therapy, the legacy use of beta-blockers after uncomplicated MI without reduced LVEF is uncertain.

Patients

Adults with type 1/2 MI, invasive care during index stay, LVEF >40%; n=8438 (Spain/Italy); 51% STEMI; contemporary guideline-directed therapy.

Intervention

Oral beta-blocker at/soon after discharge (mostly bisoprolol); agent and dose at clinician discretion.

Control

No beta-blocker; otherwise identical care.

Outcome

Primary: composite of all-cause death, reinfarction, or heart-failure hospitalization; centrally, blindly adjudicated.

Follow up period

Median 3.7 years; assessments at 3, 15, 36, and 48 months; 0.8% lost.

Results

Outcome Beta-blocker No beta-blocker Effect (HR, 95% CI) Absolute difference NNT/NNH
Primary: Death, reinfarction, or HF hospitalization 316/4207 (7.5%) 307/4231 (7.3%) 1.04 (0.89–1.22) +0.26% NNH ≈ 390
Secondary: All-cause death 161/4207 (3.8%) 153/4231 (3.6%) 1.06 (0.85–1.33) +0.21% NNH ≈ 470
Secondary: Reinfarction 143/4207 (3.4%) 143/4231 (3.4%) 1.01 (0.80–1.27) +0.02% NNH ≈ 5000
Secondary: HF hospitalization 39/4207 (0.9%) 44/4231 (1.0%) 0.89 (0.58–1.38) −0.11% NNT ≈ 900

Limitations

  • Open-label; crossover occurred.
  • Lower-than-expected event rates.
  • Time-to-event absolute risks approximated for NNT/NNH.
  • Dose/agent not protocol-mandated.
  • Subgroup signals (women, STEMI) hypothesis-generating.

Funding

Spanish public cardiovascular research institutes; low commercial bias.

Citation

Ibanez B, et al. N Engl J Med. 2025;393:1889-1900. doi:10.1056/NEJMoa2504735.