Comparing Metoprolol vs. Bisoprolol in Acute Myocardial Infarction (AMI): ESC 2026 Update

Bisoprolol was associated with higher all-cause and cardiovascular mortality compared with metoprolol in patients with Acute Myocardial Infarction, a recent study reported.

The findings were presented at the European Society of Cardiology (ESC) Congress 2026, held at Messe München, Munich, Germany, from August 28 to 31, 2026.

Why Was This Study Needed?

Beta-blockers are Class I recommendations for acute myocardial infarction (AMI). However, guidelines do not differentiate among beta-blockers within this class. Previous comparative trials have primarily focused on heart failure patients or compared non-selective versus selective beta-blockers, with limited attention to within-class differences.

Metoprolol and bisoprolol are commonly prescribed beta-blockers in patients with AMI, but their comparative effectiveness remains unclear due to the lack of head-to-head clinical trials. To address this evidence gap, researchers conducted a target trial emulation study using real-world data to compare the effectiveness of metoprolol versus bisoprolol on one-year clinical outcomes in patients with AMI.

Study Design and Patient Population

The target trial emulation study analysed real-world data from a large electronic health record system between 2013 and 2022. Researchers included patients hospitalised with AMI who received either metoprolol or bisoprolol and used a new-user design with 1:1 propensity score matching to simulate random treatment allocation.

Among 61,899 eligible patients, 9,744 patients were matched for analysis, including 4,872 patients receiving metoprolol and 4,872 receiving bisoprolol. In the intention-to-treat analysis, patients were followed for one year or until death.

The primary outcome was one-year all-cause mortality. Secondary outcomes included one-year cardiovascular mortality, recurrent myocardial infarction, and stroke.

Some of the key findings from the study include:

Higher All-Cause Mortality with Bisoprolol

• At one-year follow-up, bisoprolol use was associated with a higher risk of all-cause mortality compared with metoprolol.
• The risk of all-cause mortality was significantly higher with bisoprolol (HR 1.35; 95% CI 1.14–1.61; p=0.001), with consistent results in per-protocol analysis.

Figure 1: Metoprolol vs Bisoprolol: Real-World Evidence in AMI

Dose-Dependent Mortality Risk Observed

• Dose-stratified analysis showed an increasing mortality risk with higher bisoprolol exposure.
• Patients receiving >25% to 50% of the target dose showed increased mortality risk (HR 1.64; 95% CI 1.15–2.36; p=0.007).
• The risk was further increased among patients receiving >50% of the target dose (HR 4.11; 95% CI 2.00–8.44; p<0.001).

Cardiovascular Mortality

• Bisoprolol was associated with a higher risk of cardiovascular mortality compared with metoprolol.
• The hazard ratio for cardiovascular mortality was 1.31 (95% CI 1.05–1.63; p=0.016).
• No significant differences were observed between bisoprolol and metoprolol for recurrent myocardial infarction (HR 1.07; 95% CI 0.90–1.26; p=0.454) or stroke (HR 1.04; 95% CI 0.84–1.29; p=0.739).

Study Conclusion

These study findings concluded that, in this real-world AMI population, bisoprolol was associated with higher all-cause and cardiovascular mortality compared with metoprolol, with a dose-dependent relationship observed.

Abbreviation: AMI: Acute Myocardial Infarction, PSM: Propensity Score Matching, HR: Hazard Ratio, CI: Confidence Interval, MI: Myocardial Infarction, CV: Cardiovascular, ESC: European Society of Cardiology, ECG: Electrocardiogram

Adapted from: Yang T, Li L, Zhu W, et al. Metoprolol versus bisoprolol in patients with acute myocardial infarction: a target trial emulation study. ESC Congress 2026, Munich, Germany, August 28–31, 2026.