SMART‑DECISION: Discontinuing Beta‑Blockers After MI in Low‑Risk Patients

Discontinuing beta‑blocker therapy was noninferior to continuing it among stable, low‑risk patients who had taken the drugs for at least one year after a myocardial infarction (MI), according to the SMART‑DECISION trial, presented at ACC.26 and published in NEJM. 

In this open‑label, noninferiority study from 25 centers in South Korea, 2,540 patients with an LVEF ≥40%, no heart failure (HF), and at least one year of post‑MI beta‑blocker use were randomized 1:1 to discontinuation (n=1,246) or continuation (n=1,294). 

The cohort had a mean age of 63 years and 87% men.

At a median follow‑up of 3.1 years, the primary composite of death from any cause, recurrent MI, or HF hospitalization occurred in 7.2% of the discontinuation group versus 9.0% of the continuation group (HR 0.80; 95% CI 0.57–1.13; p=0.001 for noninferiority).

 Secondary endpoints—including individual components of the composite, new‑onset atrial fibrillation, LV‑function changes, quality‑of‑life scores, and serious adverse events—were similar between groups.

The senior investigator concludes that for appropriately selected MI survivors without HF or left‑ventricular systolic dysfunction, routine lifelong beta‑blocker continuation may not be necessary, and that discontinuation can be considered through shared decision‑making, with close monitoring of blood pressure and heart rate. 

The case is particularly strong for patients who experience beta‑blocker‑related side effects (fatigue, dizziness, bradycardia, hypotension). 

For cardiology practice, SMART‑DECISION supports a more individualized, risk‑based approach to beta‑blocker duration after MI in low‑risk, stable patients.