Beta-blockers after myocardial infarction with preserved or mildly reduced ejection fraction: existing evidence, knowledge gaps, and an EF-stratified framework

Background: For several decades, beta-blockers (BBs) have served as a cornerstone in the secondary prevention following myocardial infarction (MI). However, contemporary randomized evidence has challenged the long-term BB use in patients with preserved or mildly reduced left ventricular ejection fraction (LVEF) in the era of percutaneous coronary intervention and comprehensive guideline-directed medical therapy. Methods: We summarized evidence from three randomized controlled trials and two contemporary meta-analyses, evaluating BB therapy in post-MI patients with preserved or mildly reduced LVEF. We critically appraised trial designs, endpoints, and outcomes stratified by LVEF, and reviewed current guideline recommendations from North American and European perspectives. Results: = 0.031), with no between-trial heterogeneity. Safety profiles were comparable between BB and no-BB groups across all trials. Conclusion: Contemporary evidence supports an EF-stratified approach to BB therapy after MI. Routine long-term BB prescription may no longer be justified for patients with preserved LVEF (≥50%) without other indications, whereas BB therapy may be reasonable to consider for those with mildly reduced LVEF (40%-49%). These findings support an EF-stratified approach to long-term BB use after MI in contemporary practice.