Beta-Blocker Therapy After Revascularized AMI With Preserved LVEF: Insights From the REDUCE-AMI Trial

Beta-blockers have historically been considered a cornerstone of therapy after acute myocardial infarction (AMI), independent of left ventricular ejection fraction (LVEF). The REDUCE-AMI (Randomized Evaluation of Decreased Usage of Beta-Blockers After Acute Myocardial Infarction) trial was a registry-based, international, open-label, multicenter randomized trial designed to assess the impact of beta-blocker therapy after revascularized AMI in patients with preserved LVEF in the current era of widely available percutaneous coronary revascularization and medical therapy.^[1] The primary endpoint was a composite of death from any cause or new myocardial infarction (MI).

In the REDUCE-AMI trial, 5,020 patients with AMI with preserved LVEF (>50%) were randomized 1:1 to receive beta blockage with oral bisoprolol titrated to ≥5 mg daily or metoprolol titrated to ≥100 mg daily versus usual care. After a mean follow-up of 3.5 years, the primary endpoint of the composite of death from any cause or new MI occurred in 7.9% of patients in the beta-blocker group and in 8.3% in the no–beta-blocker group (hazard ratio, 0.96; 95% confidence interval, 0.79-1.16; p = 0.64).

The REDUCE-AMI trial results showed that, in patients with AMI who underwent percutaneous revascularization and had preserved LVEF, beta-blockers did not result in a lower incidence of composite death or new AMI, all-cause death, AMI, or heart failure hospitalization. Limitations included: 1) this was not a blinded study because patients not in the beta-blocker arm did not receive placebo, which may have introduced bias; 2) there are questions about the overall generalizability of this study given that it mostly enrolled patients in Sweden; 3) there was significant crossover between groups at 1 year, with 14% of patients randomized to usual care on beta-blockers in addition to difficulty assessing medical adherence; and 4) the clinical endpoints were assessed via registry data and were not centrally adjudicated. Overall, the results of the REDUCE-AMI challenge traditional medical practice, although beta-blockers should be considered for patients with AMI who have other clinical indications.

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