Clinical Decisions on Beta Blockers After MI

Clinical Question

In adults with acute myocardial infarction and preserved left ventricular ejection fraction (LVEF), does initiating beta-blocker therapy at discharge, compared with no beta-blocker therapy, reduce the risk of death or recurrent myocardial infarction?

Background

Beta-blockers have long been a cornerstone of post–myocardial infarction care, largely based on trials conducted in the pre-reperfusion era. However, with modern advances in revascularization and medical therapy, the benefit of routine beta-blocker use—particularly in patients with preserved left ventricular function—has been called into question. Prior observational studies and registry data have shown conflicting results, and randomized controlled trials in this specific population remain limited, making this a timely and clinically relevant issue.

Design

The most recent Clinical Decisions article from the New England Journal of Medicine addresses this question. Clinical Decisions present real-world patient cases followed by differing expert opinions to guide clinical decision-making. These pieces are not clinical trials but are designed to stimulate discussion around areas of clinical uncertainty, drawing on evidence, guidelines, and expert judgment.

Clinical Case

In this vignette, a 70-year-old man with a history of hypertension and hyperlipidaemia presents with a non–ST-segment elevation myocardial infarction. He undergoes successful percutaneous coronary intervention with a drug-eluting stent and is found to have preserved left ventricular ejection fraction. As he recovers and prepares for discharge, the clinical team must decide whether to initiate beta-blocker therapy in the absence of a clear indication such as heart failure or reduced LVEF.

Outcome

The article presents two expert perspectives: one in favour of initiating beta-blockers, citing potential benefits in reducing arrhythmic risk and sympathetic overactivation, and another arguing against their use, highlighting the lack of clear mortality benefit in patients with preserved LVEF in the modern era. These contrasting viewpoints are intended to help readers navigate the uncertainty by weighing current evidence and applying it to individualized patient care.

Strengths

A key strength of the Clinical Decisions format is its interactive nature, which actively engages readers in the decision-making process. Clinicians are invited to vote on nejm.org, sharing how they would manage the case, and the collective results—along with expert commentary—are published a few weeks later, fostering ongoing dialogue and reflection on evidence-based care.

The Bottom Line

This Clinical Decisions piece underscores the ongoing debate about routine beta-blocker use after acute myocardial infarction in patients with preserved LVEF, where evidence is evolving and nuanced. In clinical practice, decisions should be individualized, weighing patient-specific risk factors, comorbidities, and preferences until more definitive trial data become available.

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