Beta-Blockers After Heart Attack

What did SMART-DECISION find about stopping beta-blockers?

The debate over deprescribing heart medicines has gained evidence from SMART-DECISION, published in March 2026. Researchers enrolled heart attack survivors without heart failure whose left ventricular ejection fraction was at least 40%. Ejection fraction measures the proportion of blood expelled by the heart's main pumping chamber with each contraction; this threshold does not mean every participant had normal pumping function.

Participants were randomly assigned to stop or continue beta-blockers. Withdrawal met the study's predefined noninferiority criterion for the combined outcome of death, another heart attack, or hospitalization for heart failure. This means any disadvantage remained within the trial's statistical boundary; it does not establish identical outcomes or prove that stopping is better. Both patients and clinicians knew the assigned treatment. [SMART-DECISION trial](https://doi.org/10.1056/NEJMoa2601005)

Why did the ABYSS trial produce a different conclusion?

ABYSS, published in 2024, studied people already taking beta-blockers after a heart attack, with an ejection fraction of at least 40%. Its main outcome included death, another heart attack, stroke, or hospitalization for any cardiovascular reason. Events occurred in 23.8% of the interruption group and 21.1% of the continuation group. Stopping treatment failed to meet the trial's noninferiority criterion and did not improve measured quality of life. [ABYSS trial](https://www.nejm.org/doi/full/10.1056/NEJMoa2404204)

A key distinction is what counted as an event: ABYSS included a wider range of cardiovascular hospitalizations than SMART-DECISION. The studies also used different noninferiority margins. These design differences help interpret their contrasting conclusions, although they do not establish the cause of the disagreement. Comparing headline percentages directly would overlook those differences.

How should patients approach a beta-blocker medication review?

Beta-blockers slow the heartbeat and can treat angina, certain abnormal heart rhythms, high blood pressure, and some forms of heart failure. A prescription started after a heart attack may therefore continue to serve another purpose. Fatigue, dizziness, or other troublesome side effects are reasons to discuss treatment with a clinician, but they do not by themselves establish that withdrawal is appropriate. [NHS beta-blocker guidance](https://www.nhs.uk/medicines/beta-blockers/)

Patients should bring their medication list and describe symptoms, including when they occur, to their review. If withdrawal is appropriate, the prescriber should specify how to reduce treatment and arrange follow-up. Stopping suddenly can worsen the underlying condition; gradual dose reduction may be necessary. The practical implication of these trials is a more informed conversation about continued treatment, with monitoring tailored to the reason the drug was prescribed. [NHS patient information on heart medicines](https://www.rwt.nhs.uk/PIL/MI_10701014_20.09.22_V_1.pdf)