#3-49E. Rethinking Routine Beta-Blockers for Preserved Ejection Fraction (N Engl J Med, 2026)

For decades, beta-blockers have been a cornerstone of post-myocardial infarction care, but recent data compels us to question their utility in patients with preserved heart function. This episode examines a landmark meta-analysis of individual-patient data from five randomized trials involving 17,801 patients with a recent myocardial infarction and a left ventricular ejection fraction of at least 50%. The study compared beta-blocker therapy against no treatment and found no significant difference in the primary composite endpoint of all-cause death, myocardial infarction, or heart failure. This pivotal finding suggests that routine beta-blocker administration provides no clinical benefit in this specific low-risk population. However, critical appraisal is necessary; the included trials were open-label, which may introduce performance bias, and the strict exclusion of patients with other indications for beta-blockers limits generalizability. Nevertheless, for physicians, this evidence supports a major shift in practice, empowering clinicians to confidently forego routine beta-blockers in patients with preserved ejection fraction, thereby reducing pill burden and potential side effects without compromising cardiovascular safety.

Citation: Kristensen AMD, et al. Beta-Blockers after Myocardial Infarction with Normal Ejection Fraction. N Engl J Med. 2026. DOI: 10.1056/NEJMoa2512686

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