REDUCE-AMI: Re-evaluating the role of routine beta-blockade in patients with acute myocardial infarction

In patients with acute myocardial infarction (MI) and a preserved ejection fraction (EF) of at least 50%, events of death or new MI were not reduced by long-term beta-blocker therapy. Also, there was no evidence of a significant effect of beta-blockers on secondary outcomes or safety endpoints in the REDUCE-AMI trial.

In post-MI patients with reduced EF, beta-blocker treatment has demonstrated a clear mortality reduction, but its benefit for those with a preserved EF who are revascularised is uncertain in the era of reperfusion treatment [1]. To generate more data to clarify this matter, Dr Troels Yndigegn (Lund University, Sweden) and colleagues designed the phase 4 REDUCE-AMI trial (NCT03278509).

This registry-based prospective, randomised, open-label trial included over 5,000 adults who received early coronary angiography and had an EF ≥50% after an MI between 2017 and 2023. The beta-blocker group was treated with either daily 100 mg metoprolol succinate or 5 mg bisoprolol, and participants were encouraged to continue treatment post-discharge. The other study arm received no beta-blockers unless there was an indication beyond secondary prevention. The study cohort had a median age of 65 years and included about 22% women. “There was a high degree of adherence to guideline-directed therapy,” Dr Yndigegn noted. Participants were followed over a median of 3.5 years.

The primary composite outcome of all-cause death or new MI showed no significant difference between groups: 199 events were observed for participants on beta-blockers and 208 events for those not on beta-blockers (HR 0.96; 95% CI 0.79–1.16; P=0.64). Also, no reductions were found for any of the secondary outcomes, and the analysis of all prespecified subgroups suggested similar treatment effects regarding the primary outcome.

The safety endpoints showed overall similar risks between the study arms. This included bradycardia, hypotension, asthma, and hospitalisation for stroke.

“All therapies need an expiration date or re-evaluation when there is a change in underlying risk due to advancement in medical therapy; in patients with MI and preserved EF who underwent prompt revascularisation and were on guideline-directed medical therapy, there is no role for beta-blockers to improve clinical outcomes or symptoms,” said discussant Prof. Sripal Bangalore (New York University School of Medicine, NY, USA) [2]. He also emphasised that in patients with heart failure with reduced EF, beta-blockers should continue to be the cornerstone of therapy.

1. 
   
   1. Yndigegn T. Long-term beta-blocker treatment after acute myocardial infarction and preserved left ventricular ejection fraction - the REDUCE-AMI trial. LB3, Session 406, ACC 2024 Scientific Session, 6–8 April, Atlanta, USA.
   2. Bangalore S. The REDUCE-AMI trial. Session 414, ACC 2024 Scientific Session, 6–8 April, Atlanta, USA.

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Posted on 16 May 202413 June 2024