Madrid, Spain – 30 August 2025: Beta-blocker therapy significantly reduced a composite endpoint of all-cause mortality and major adverse cardiovascular events compared with no beta-blocker therapy in patients with myocardial infarction (MI) and preserved or mildly reduced left ventricular ejection fraction (LVEF), according to late-breaking research from the BETAMI and DANBLOCK trials presented in a Hot Line session today at ESC Congress 20251 and simultaneously published in the New England Journal of Medicine.
“Evidence supporting beta-blocker therapy after MI was established before the introduction of modern coronary reperfusion therapy and secondary prevention strategies,” explained Principal Co-Investigator and presenter, Professor Dan Atar from Oslo University Hospital Ullevaal, Norway. “And while beta-blockers are strongly recommended for patients with MI and reduced LVEF,2 their role in MI patients with preserved or mildly reduced LVEF (≥40%) without heart failure is less certain,” he noted. Two randomised trials with almost identical designs – the Norwegian BETAMI trial and the Danish DANBLOCK trial – were combined to assess the effects of beta-blocker therapy on cardiovascular outcomes in patients after MI who had LVEF ≥40% and no clinical heart failure.
In the two randomised open-label blinded-endpoint trials, eligible participants were enrolled within 7 days (BETAMI) or 14 days (DANBLOCK) of an MI if they had LVEF ≥40% and no clinical diagnosis of heart failure. Participants were randomised 1:1 to long-term beta-blocker or no beta-blocker therapy. The primary endpoint was a composite of all-cause mortality, new MI, unplanned coronary revascularisation, ischaemic stroke, heart failure or malignant ventricular arrhythmias.
Among 5,574 participants who underwent randomisation, the median age was 63 years and 20.8% were women. A total of 10.5% had a history of coronary artery disease and 8.4% were on beta-blocker treatment prior to enrolment.
After a median follow-up of 3.5 years, the incidence of the primary endpoint event was significantly lower in the beta-blocker group than in the no beta-blocker group (14.2% vs. 16.3%; hazard ratio [HR] 0.85; 95% confidence interval [CI] 0.75 to 0.98; p=0.027). All-cause mortality occurred in 4.2% and 4.4% of patients on beta-blocker therapy and no-beta blocker therapy, respectively (HR 0.94; 95% CI 0.73 to 1.21), while a new MI occurred in 5.0% and 6.7% of patients, respectively (HR 0.73; 95% CI 0.59 to 0.92). There were no apparent differences in the risk of heart failure, malignant ventricular arrhythmias, unplanned coronary revascularisation or ischaemic stroke between patients who received beta-blockers and those who did not, but the statistical power for these individual outcomes was limited.
Although not powered to address the subgroup of patients with mildly reduced LVEF (40−49%), the HR for the primary endpoint was 0.82 (95% CI 0.65 to 1.02) among 854 patients. A meta-analysis of data from patients with mildly reduced LVEF (40−49%) from four trials, including BETAMI and DANBLOCK, will be presented at the same Hot Line session today.3
Regarding safety, a composite of all-cause mortality, MI, heart failure or malignant ventricular arrhythmia at 30 days occurred in 0.8% of patients in the beta-blocker group and 1.1% in the no beta-blocker group. Serious adverse events appeared similarly low between the groups.
Summarising the findings, Principal Co-Investigator, Professor Eva Prescott from Copenhagen University Hospital – Bispebjerg and Frederiksberg, Denmark, said: “Long-term beta-blocker therapy reduced the composite of all-cause mortality and major adverse cardiovascular events in this patient population, with a notable decrease in the incidence of new MI. Our findings suggest that, despite advances in contemporary MI treatment, the beneficial effects of beta-blocker therapy remain clinically relevant, even in patients without reduced LVEF or heart failure. However, the results must be considered alongside other recent and ongoing trials of beta-blocker therapy after MI to determine their implications for clinical practice.”
ENDS
Notes to editor
This press release accompanies both a presentation and an ESC press conference at ESC Congress 2025.
It does not necessarily reflect the opinion of the European Society of Cardiology.
Funding: The BETAMI trial received grants from the Health South-East Research Program in Norway and the Research Council of Norway, with no industry support. The DANBLOCK trial was supported by grants from the Danish Heart Foundation and the Novo Nordisk Foundation.
Disclosures: Professor Atar reports speaker fees from Abbott, Amgen, Amarin, AstraZeneca, Bayer, Boehringer-Ingelheim, BMS, Chiesi, GSK, MSD, Novartis, Novo Nordisk, Pfizer, Pharmacosmos, Philips, Roche-Diagnostics, Sanofi, Takeda and Vifor and grant support (to his institution) from BMS/Pfizer, Medtronic, Bayer and Roche-Diagnostics. Professor Prescott reports no disclosures.
About the study population: In a myocardial infarction (MI; heart attack), one of the coronary arteries becomes blocked and the heart muscle is not supplied with sufficient oxygen. In some patients, the MI can cause long-term damage such that the patient develops heart failure – a condition in which the pumping action of the heart is impaired.
After an MI, the pumping ability of the heart is assessed by measuring the left ventricular ejection fraction (LVEF): the amount of blood that is pumped out of the left ventricle during each heartbeat. An LVEF less than 40% indicates that the heart is pumping weakly and the ejection fraction is said to be ‘reduced’. An LVEF between 40% and 50% indicates slightly impaired pumping abilities and the ejection fraction is said to be ‘mildly reduced’. An LVEF more than 50% indicates that the heart is pumping normally, and the ejection fraction is said to be ‘preserved’, although there may still be problems with ventricle stiffening.
References and notes:
1‘BETAMI-DANBLOCK trial: Randomised discontinuation of beta-blockers after myocardial infarction’ presented during HOT LINE 3 on 30 August 2025 at 11:10 to 11:20 in Madrid (Main Auditorium) and simultaneously published in the New England Journal of Medicine.
2Byrne RA, Rossello X, Coughlan JJ, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023;44:3720–3826.
3‘REBOOT/BETAMI/DANBLOCK/CAPITAL-RCT: Beta-blockers after MI with mildly reduced EF (an IPD meta-analysis)’ presented during HOT LINE 3 on 30 August 2025 at 11:20 to 11:30 in Madrid (Main Auditorium).
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