Determining major adverse cardiovascular event risk of beta-blocker discontinuation after acute coronary syndromes

Introduction: Beta-blocker therapy reduced mortality and cardiovascular events following acute coronary syndromes (ACS) in the pre-reperfusion era. In the contemporary era of early mechanical reperfusion and modern secondary prevention, the benefit of beta-blockers after ACS without reduced left ventricular ejection fraction (LVEF) has been questioned. This review was based on PubMed database searches from inception to January 2025. Areas covered: The recent REDUCE-AMI and ABYSS trials were the first adequately powered contemporary randomized trials evaluating beta-blockers after ACS without reduced LVEF. Contemporary observational evidence is also discussed. Implications for different LVEF categories (41-49% versus >= 50%), ACS subtypes, beta-blocker therapy duration, optimal dose, and interaction with other secondary prevention therapies are addressed. Expert opinion: We estimate that there is sufficient evidence to abandon routine beta-blocker prescription in post-ACS patients with preserved LVEF >= 50%. Beta-blocker prescription should be individualized with shared decision-making, balancing the risk of cardiovascular event against potential benefits of deprescription. Factors favoring beta-blocker discontinuation include adverse effects, polypharmacy, >1-3 years of stability post-ACS, and specific comorbidities (e.g. heart failure with preserved LVEF). Factors favoring beta-blocker prescription/continuation (besides established indications such as LVEF <= 40%, arrhythmias, angina, and refractory hypertension) include good tolerance, LVEF 41-49%, and non-adherence to other secondary prevention therapies.