ESC 2025 | What Should We Do With Beta-Blockers Post-MI in Patients With Preserved LVEF?

The evidence supporting the use of beta-blockers after myocardial infarction (MI) is strong in patients with ventricular dysfunction (LVEF ≤40%). However, in those with preserved or mildly reduced function, results have been inconsistent. At ESC 2025, two major trials addressed this question.

REBOOT: Beta-Blockers Post-MI With Preserved Ejection Fraction

The REBOOT trial was a prospective, randomized, controlled study that included 8,438 patients over 18 years old, discharged after an MI with LVEF >40% and invasive management during hospitalization. At discharge, patients were randomized to receive or not receive beta-blockers, with the choice of drug and dosage left to the treating physician.

The median follow-up was 3.7 years. The study population had a mean age of 61 years, 19.5% were women, 51% presented with STEMI and 49% with NSTEMI; 94% underwent PCI and 88% achieved complete revascularization. The primary endpoint (all-cause mortality, nonfatal reinfarction, or hospitalization for heart failure) occurred in 316 patients treated with beta-blockers (22.5/1000 patient-years) and in 307 patients in the control group (21.7/1000 patient-years), with no significant difference.

Reference: Borja Ibáñez, MD PhD FESC, on behalf of the REBOOT-CNIC investigators.

Read also: ESC 2025 | AMALFI: Remote Monitoring for Atrial Fibrillation Detection.

BETAMI-DANBLOCK: Randomized Discontinuation of Beta-Blockers Post-MI

This randomized, open-label, independently funded trial included 5,574 patients in Norway and Denmark within 14 days of MI, with LVEF ≥40% and who had undergone revascularization. Patients were randomized to receive beta-blockers (within 14 days post-MI) or not. In the treatment group, metoprolol was used in 95% of cases (median dose: 50 mg). The median follow-up was 3.5 years.

The primary endpoint (all-cause mortality or major cardiovascular events: reinfarction, unplanned revascularization, heart failure, ischemic stroke, or malignant ventricular arrhythmias) showed a significant reduction in the beta-blocker group compared with control (relative risk reduction of 17%; p=0.01).

Reference: Dan Atar, Prof. dr.med., Oslo University Hospital, Norway, on behalf of the BETAMI-DANBLOCK investigators.

Read also: ESC 2025 | DANCAVAS 2: Cardiovascular Screening in Men Aged 60 to 64 Years.

Conclusion

While REBOOT did not show a benefit from routine beta-blocker use in post-MI patients with LVEF >40%, BETAMI-DANBLOCK, with a robust design and a similar population, demonstrated that beta-blocker therapy reduced mortality and major cardiovascular events. These seemingly contradictory results highlight the complexity of the issue and suggest that post-MI beta-blocker therapy in patients with preserved LVEF should be individualized in light of current evidence.