Stopping beta-blockers years after heart attack is safe
In stable patients years after a heart attack, stopping beta-blockers was no worse than continuing them for death, another heart attack, or heart-failure hospitalization.
*Open-label randomized noninferiority trial; Level 1b (OCEBM).

Citation

Choi KH, Kang D, Kim W, et al.; SMART-DECISION Investigators. Discontinuation of Beta-Blocker Therapy after Myocardial Infarction. New England Journal of Medicine. 2026;394:1302-1312. doi:10.1056/NEJMoa2601005.

Background

Many people remain on beta-blockers long after a heart attack, even when their heart pumping function is preserved and they have no heart failure. Whether long-term continuation helps this lower-risk group is uncertain.

Patients

2540 stable adults in South Korea with prior myocardial infarction, left ventricular ejection fraction at least 40%, no heart failure, and on beta-blockers for at least 1 year. Key exclusions: ejection fraction below 40%, ongoing heart failure treatment, atrial fibrillation, or beta-blocker contraindications.

Intervention

Immediate discontinuation of beta-blocker therapy.

Control

Continue the same beta-blocker and dose.

Outcome

(Primary) Composite of death from any cause, recurrent myocardial infarction, or hospitalization for heart failure (noninferiority margin: upper 95% confidence limit below 1.4 for the hazard ratio).

Follow-up Period

Median 3.1 years (interquartile range, 2.5 to 3.5).

Results

Outcome Stopped beta-blocker Continued beta-blocker Conclusion
Death, recurrent myocardial infarction, or heart-failure hospitalization (primary) 7.2% (4-year estimate) 9.0% (4-year estimate) Noninferior (met prespecified margin)
Serious adverse events were similar between groups. Analyses were intention-to-treat; per-protocol results were consistent. This was a noninferiority trial.

Limitations

Open-label design could influence some care decisions, although outcomes were mostly objective and independently reviewed. Participants were a selected, very stable group enrolled years after the heart attack, limiting applicability to earlier or higher-risk patients. The noninferiority margin was relatively wide and event rates were low, reducing precision. Few women were enrolled, making results less certain for women.

Funding

Patient-Centered Clinical Research Coordinating Center, South Korea Ministry of Health and Welfare.

Clinical Application

For stable post–myocardial infarction patients (ejection fraction ≥40%, no heart failure), consider stopping beta-blockers after ≥1 year; monitor blood pressure and heart rate.