Key take-aways 

• While beta-blockers are strongly recommended for patients with myocardial infarction (MI) and reduced left ventricular ejection fraction (LVEF), their role in patients with preserved or mildly reduced LVEF (≥40%) is less certain. 
• The BETAMI-DANBLOCK trials investigated the effect of beta-blockers vs. no beta-blockers on the primary endpoint of all-cause mortality and major adverse cardiovascular events in patients after an MI with LVEF ≥40%. 
• A significant reduction in the primary endpoint was observed with beta-blockers compared with no beta-blockers. 
• These results suggest that, despite advances in contemporary MI treatment, the beneficial effects of beta-blockers remain clinically relevant, even in patients with preserved or mildly reduced LVEF. 

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