The REDUCE-AMI trial, published in the New England Journal of Medicine, is prompting a re-evaluation of long-term beta-blocker use in patients following acute myocardial infarction (AMI). The study challenges the conventional wisdom of routine beta-blocker prescriptions for all post-AMI patients, particularly those with preserved left ventricular ejection fraction (LVEF).
The parallel-group, open-label trial, involved 5,020 patients with AMI who underwent early coronary angiography and had an LVEF of at least 50%. Participants were randomized to either long-term beta-blocker treatment (n=2508) or no beta-blocker treatment (n=2512). Over a median follow-up of 3.5 years, the primary endpoint (death from any cause or new MI) occurred in 7.9% of patients in the beta-blocker group and 8.3% in the no-beta-blocker group (hazard ratio, 0.96; 95% CI, 0.79-1.16; P =.64).
Implications for Clinical Practice
"Despite the lack of clear evidence of benefit in the contemporary setting, current guidelines widely recommend beta-blocker use after myocardial infarction," wrote study authors Yndigegn et al. The trial sought to provide new data regarding the necessity of beta-blocker use in patients with preserved LVEF.
According to Christopher Granger, MD, the Fred Cobb MD Distinguished Professor of Medicine at Duke University School of Medicine, the REDUCE-AMI trial results suggest that "routine beta-blockers for patients like those included in that trial (revascularized 1- or 2-vessel disease and LVEF ≥50%) is no longer necessary."
Gregg Fonarow, MD, interim chief of the division of cardiology at UCLA, noted that most trials supporting beta-blocker benefits were conducted before routine reperfusion, revascularization, antiplatelet drugs, statins, and RAAS inhibitors. He suggests that for patients with LVEF of 50% or higher, "routine use of beta-blockers should be reconsidered, pending additional evidence."
Expert Perspectives on Beta-Blocker Use
Carlin S Long, MD, professor of medicine and cardiology at the University of California, San Francisco, emphasized that current guidelines are based on decades-old data. While beta-blockers have a clear role in patients with reduced LVEF (40% or less), their benefit in those with preserved LVEF is less certain.
"For patients with preserved LVEF, the lack of observed benefit in reducing death or new MI needs to be weighed against the potential side effects and quality of life implications of beta-blocker therapy," Dr. Long stated. She advocates for a more refined and individualized approach to beta-blocker use post-AMI.
Shared Decision-Making
Experts recommend shared decision-making with patients, clearly explaining the potential benefits and risks of beta-blockers. This includes assessing patient preferences, goals, and lifestyle, as well as considering comorbidities and current medications.
Future Research Needs
Further studies are needed to evaluate the long-term outcomes of beta-blocker therapy in patients with preserved LVEF post-AMI. Subgroup analyses are also necessary to identify specific patient populations who might still benefit from beta-blockers, even with preserved LVEF.
Fonarow also highlighted the need to optimize the use of other evidence-based therapies, such as high-intensity statins, combination lipid-lowering therapy, mineralocorticoid receptor antagonists, and cardiac rehabilitation.
The REDUCE-AMI trial underscores the importance of tailoring post-AMI management to individual patient profiles, potentially leading to changes in clinical practice and guideline recommendations.
