Hot Line 3: REBOOT/BETAMI/DANBLOCK/CAPITAL-RCT meta-analysis
31 Aug 2025
Hot Line ESC Congress 2025 Beta-blockers in patients after MI with LVEF 40–49%:
“Trials have assessed beta-blockers after a recent myocardial infarction (MI) in patients with LVEF ≥40%; however, none was individually powered to assess effects in the mildly reduced LVEF 40–49% subgroup,” explained Doctor Xavier Rosselló (Centro Nacional de Investigaciones Cardiovasculares Carlos III [CNIC] - Madrid and the Son Espases University Hospital - Palma de Mallorca, Spain). A systematic review was conducted of randomised controlled trials with beta-blockers performed in the reperfusion era (from 2000) with a median follow-up of more than 1 year in patients with a recent (within 14 days) MI (both ST-elevation or non-ST-elevation MI), mildly reduced LVEF and no history or clinical signs of heart failure (HF). Four trials were identified: REBOOT conducted in Spain and Italy, BETAMI in Norway, DANBLOCK in Denmark and CAPITAL-RCT in Japan. A prespecified, individual patient level meta-analysis across the four trials assessed the effect of beta-blockers on the primary composite endpoint of all-cause death, new MI or HF.
Overall, 1,885 patients with mildly reduced LVEF were analysed from the four trials (979 patients from REBOOT, 422 from BETAMI, 430 from DANBLOCK and 54 from CAPITAL-RCT), making up 13.1% of the study populations from the main trials.
The primary endpoint occurred in 10.7% of patients in the beta-blocker group and 14.4% of patients in the no beta-blocker group, representing a significant 25% relative reduction with beta-blockers (hazard ratio [HR] 0.75; 95% CI 0.58 to 0.97; p=0.031).
There was no apparent heterogeneity in the effect on the primary endpoint between the four trials or between the countries of enrolment (Spain, Italy, Norway, Denmark and Japan).
The three individual components of the primary endpoint followed the same direction as the composite endpoint. All-cause death occurred in 5.9% and 7.7% of patients in the beta-blocker and no beta-blocker groups, respectively (HR 0.78; 95% CI 0.55 to 1.11). New MI occurred in 3.9% and 5.2% of patients, respectively (HR 0.77; 95% CI 0.55 to 1.11), while HF occurred in 3.0% and 4.4% of patients, respectively (HR 0.71; 95% CI 0.44 to 1.14). In addition, cardiac death was found to occur in 1.8% of patients on beta-blockers and 3.3% of patients with no beta-blockers (HR 0.55; 95% CI 0.28 to 1.06).
Concluding, Dr. Rosselló said: “Our findings extend the known benefits of these agents in MI patients with reduced LVEF to the subgroup with mildly reduced LVEF. Further research should now focus on patients with preserved LVEF (>50%).”
