A new study suggests that beta-blockers—long considered a lifelong therapy following myocardial infarction (MI)—may be safely discontinued in certain patients.
Beta-blockers have traditionally been prescribed as a cornerstone of standard therapy to reduce the risk of recurrent MI and mortality. However, with recent advances in cardiovascular care, including widespread use of percutaneous coronary intervention (PCI), questions have emerged regarding the necessity of long-term beta-blocker therapy in clinically stable patients—particularly those who have maintained treatment for at least one year post-MI and have no evidence of left ventricular systolic dysfunction or heart failure.
Previously, a research team led by Professor Joo Yong Hahn of the Division of Cardiology at Samsung Medical Center conducted a large-scale observational study using data from the National Health Insurance Service (NHIS) of Korea. The study evaluated the impact of beta-blocker discontinuation on clinical outcomes in stable post-MI patients, with findings published in 2020 in the European Heart Journal. (Research Team: Professor Joo Yong Hahn, Professor Jihoon Kim, Dan Bee Kang)
To directly validate these observational findings, the SMART-DECISION trial was designed as a randomized controlled trial (RCT). Led by Professor Hahn as principal investigator, the study was supported by a five-year national research grant from the Ministry of Health and Welfare under the Patient-Centered Clinical Research Coordinating Center, and conducted in collaboration with the Korean Acute Myocardial Infarction Registry.
The research team, including Professors Joo Yong Hahn, Ki Hong Choi, and Dan Bee Kang, recently reported the trial results in the latest issue of the New England Journal of Medicine (impact factor: 78.5). The study demonstrated that, among stable post-MI patients, discontinuation of beta-blockers was not associated with a statistically significant increase in the composite outcome of all-cause mortality, recurrent MI, or hospitalization for heart failure, compared with continued therapy.
The trial enrolled 2,540 patients across 25 medical centers in Korea between April 2021 and April 2023. Eligible participants had been on beta-blocker therapy for at least one year following MI, had no diagnosis of heart failure, and had a left ventricular ejection fraction (LVEF) of ≥40%.
The mean age of participants was 63.2 years, and 87.2% were male. Patients were randomized in a 1:1 ratio to either beta-blocker discontinuation (n=1,246) or continuation (n=1,294), with a median follow-up duration of 3.1 years.
During follow-up, the primary composite endpoint—comprising all-cause death, recurrent MI, or hospitalization due to heart failure—occurred in 58 patients in the discontinuation group and 74 patients in the continuation group. These findings met the criteria for non-inferiority of discontinuation.
In other words, in patients with preserved cardiac function and clinical stability, long-term maintenance of beta-blockers may not be necessary, with discontinuation appearing to be a clinically safe alternative.
In secondary analyses, recurrent MI occurred in 25 patients in the discontinuation group and 23 patients in the continuation group, with no statistically significant differences observed across other secondary endpoints.
Professor Ki Hong Choi of Samsung Medical Center noted, “With significant advances in MI management, a growing number of patients now maintain relatively well-preserved cardiac function. This study provides important clinical evidence regarding whether long-term beta-blocker therapy is necessary in such patients.”
Professor Joo Yong Hahn added, “We have demonstrated that discontinuation of beta-blockers in stable post-MI patients is non-inferior to continuation. Although the study population was limited to Korean patients, these findings may help reduce unnecessary long-term medication use in cases where therapeutic benefit is uncertain.”
Importantly, consistent with the study’s patient-centered design, patient-reported outcomes (PROs), including quality of life measures, were incorporated as key endpoints alongside traditional clinical outcomes such as mortality and rehospitalization.
Samsung Medical Center has actively integrated patient-centered metrics and quality-of-life assessments into both clinical practice and research. Reflecting these efforts, the institution was ranked 26th globally and 1st in Korea in the “World’s Best Hospitals 2026” ranking published by Newsweek.
These recognitions are attributed, in part, to the hospital’s sustained commitment to conducting patient-centered research and systematically incorporating patient-reported outcomes into clinical trials.
The SMART-DECISION trial was selected as a Late-Breaking Clinical Trial at the American College of Cardiology (ACC) Annual Scientific Session, held on March 30 (local time) in New Orleans, where Professor Hahn presented the findings.
In March 2025, Professor Joo Yong Hahn also presented results from the SMART-CHOICE 3 trial at the same conference, demonstrating the superiority of clopidogrel over aspirin in patients undergoing coronary stenting, with findings published in The Lancet.
The research team anticipates that these results will provide critical evidence to inform long-term treatment strategies for MI patients and may contribute to a paradigm shift in pharmacologic management.