Discontinuing beta-blocker therapy was found to be noninferior to continuing the therapy among stable, low-risk patients who took it for at least one year following a myocardial infarction (MI), according to the SMART-DECISION trial presented during a Late-Breaking Clinical Trial session during ACC.26 in New Orleans and simultaneously published in NEJM.

SMART-DECISION was an open-label, noninferiority trial conducted at 25 centers in South Korea between 2021 and 2024. Of the 2,540 patients enrolled, 1,246 were randomly assigned to discontinuation of beta-blocker therapy and 1,294 to continuation of beta-blocker therapy. All patients had an LVEF of at least 40%, no heart failure (HF) and had received beta-blocker therapy for at least one year post MI. The mean age of the patients was 63 years and 87% were men.

The primary endpoint was a composite of death from any cause, recurrent MI or hospitalization for HF. At a median follow-up of 3.1 years, the primary endpoint occurred in 7.2% (n=58) of those who discontinued beta-blockers and 9.0% (n=74) of those who continued beta-blockers (hazard ratio, 0.80; 95% CI, 0.57-1.13; p=0.001 for noninferiority).

Looking at secondary endpoints, the results associated with beta-blocker discontinuation were similar, including each component of the primary composite endpoint as well as new-onset atrial fibrillation, unfavorable changes in LV function, changes in quality of life and serious adverse events.

“In appropriately selected patients who survived a heart attack and do not have [HF] or left ventricular systolic dysfunction, routine continuation of beta-blockers indefinitely may not be necessary,” says Joo-Yong Hahn, MD, the trial’s senior author. “In practice, for stable patients who are several years out from a heart attack, discontinuation can be considered through shared decision-making and with monitoring of blood pressure and heart rate. For patients with beta-blocker-related side effects – fatigue, dizziness, bradycardia, hypotension – the case for discontinuation is even stronger.”

Keywords: ACC Annual Scientific Session, ACC26, New Orleans, Myocardial Infarction, Adrenergic beta-Antagonists