• Myocardial Infarction

For many years, clinical practice guidelines have recommended beta-blockers after myocardial infarction for all patients without a contraindication. In this issue of Heart, this recommendation is questioned by a propensity adjusted analysis from the SWEDEHEART registry which found no association between long-term beta-blocker use and mortality or major cardiovascular events in 43 618 patients with previous myocardial infarction who did not have heart failure or left ventricular (LV) systolic dysfunction.1

Many clinical trials have evaluated whether beta-blockers improve clinical outcomes after myocardial infarction, but most were undertaken more than 25 years ago. In a meta-analysis published in 1999,2 randomised clinical trials that evaluated acute, short-term treatment with a beta-blocker included 29 260 patients and 3062 (10.5%) deaths. On beta-blockers, there was no significant reduction in the pooled odds ratio (OR) for death (0.96, 95% CI 0.85 to 1.08). However, for trials that evaluated longer term beta-blocker treatment, which randomised a total of 24 974 patients with 2415 (9.7%) deaths, the pooled OR for death for patients randomised to a beta-blocker was 0.77, 95% CI 0.60 to 0.85. This is a clinically important benefit comparable to other strongly recommended evidence-based therapies.

Despite strong evidence that long-term beta-blockers can improve outcomes after myocardial infarction, it has been uncertain whether this benefit applies to lower risk patients who are taking other evidence-based therapies …