Beta-Blockers Discontinuation Safe After One Year in Selected Patients after MI: SMART-DECISION Trial
South Korea: The SMART-DECISION trial has found that in stabilized patients after myocardial infarction (MI) without heart failure or left ventricular systolic dysfunction, discontinuing beta-blockers after one year is a reasonable option. Stopping therapy showed similar major clinical outcomes compared to continuation, including all-cause death, recurrent MI, or heart failure hospitalization (7.2% vs 9.0%; HR 0.80, 95% CI 0.57–1.13). This suggests that long-term beta-blocker use may not be necessary in this low-risk group.
A new study published in the New England Journal of Medicine by Ki Hong Choi and colleagues provides important insights into the ongoing debate regarding the duration of beta-blocker therapy following myocardial infarction. While beta-blockers have long been a cornerstone of post-MI management, particularly in patients with reduced cardiac function, their long-term role in patients with preserved left ventricular function remains uncertain in the modern era of advanced reperfusion strategies and secondary prevention.
To address this question, researchers conducted an open-label, randomized, noninferiority trial across 25 centers in South Korea. The study enrolled patients who had experienced an MI but remained clinically stable, had a left ventricular ejection fraction of at least 40%, and showed no signs of heart failure. All participants had already completed at least one year of beta-blocker therapy before enrollment. They were then randomly assigned to either discontinue or continue beta-blocker treatment.
A total of 2,540 patients were included in the trial, with 1,246 assigned to discontinue therapy and 1,294 continuing treatment. The average age of participants was 63.2 years, and women accounted for 12.8% of the cohort. Patients were followed for a median duration of 3.1 years to assess long-term outcomes.
The primary endpoint was a composite of all-cause mortality, recurrent myocardial infarction, or hospitalization for heart failure.
The researchers reported the following findings:
- Discontinuation of beta-blockers was found to be noninferior to continued therapy based on predefined statistical criteria.
- Rates of serious adverse events were similar between the discontinuation and continuation groups.
- Stopping beta-blockers did not increase safety risks.
- In stable patients without heart failure and with preserved ventricular function, long-term continuation may not provide additional clinical benefit.
- The findings suggest that extending beta-blocker therapy beyond one year may be unnecessary in this low-risk group.
- Reducing prolonged use could help avoid side effects such as fatigue, bradycardia, and impaired quality of life.
The study reflects evolving treatment paradigms in cardiology, where therapies are increasingly tailored based on individual risk profiles rather than applied uniformly. In the context of improved revascularization techniques and comprehensive secondary prevention measures, the necessity of indefinite beta-blocker therapy is being reconsidered.
While the findings are promising, the authors note that treatment decisions should still be individualized, taking into account patient-specific factors and clinical judgment. Nonetheless, this trial provides robust evidence supporting a more flexible approach to beta-blocker use after myocardial infarction in low-risk patients.
Reference:
DOI: 10.1056/NEJMoa2601005
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