Long-term beta-blockers not vital after heart attack – Korean study

Surviving a heart attack has long come with a lifelong prescription for beta-blockers but experts are now questioning whether this is really necessary, especially beyond the first year of recovery, reports CNN. For more than 40 years, beta-blockers have been commonly prescribed as a standard treatment for adults who have had heart attacks with no complications, to reduce the risk of another cardiovascular event, but a growing school of thought is that using them for a year or two if needed rather than a lifetime could help people avoid unnecessary side effects and save money. The American Heart Association and the American College of Cardiology regularly issue joint guidelines on treating heart conditions. In 2023, a guideline for treating patients with chronic coronary disease was updated to not recommend long-term beta-blocker therapy in these patients if they had not had a heart attack in the past year. More recent guidelines acknowledge that there is evolving data around the long-term use of the medications after a heart attack, said Dr Manesh Patel, president-elect of the American Heart Association and Cardiologist and Professor at the Duke University School of Medicine. “Beta-blockers were originally used before we had a lot of the more recent technological advances – such as opening the artery fast with angioplasty, saving the heart muscle, even some of the blood thinners and cholesterol medications we use. Those advances were just coming about when beta-blockers were first studied to show a benefit in patients after a heart attack,” Patel said. “Emerging research may allow us, in real time, to start to de-escalate some of the therapies. The evidence is changing, and for patients who are stable after having a heart attack, there’re more data on the risks and the benefits …so that you could potentially stop chronic beta-blocker therapy.” The shifting standard of care could have a “significant” impact on how much money heart attack survivors may spend on beta-blockers throughout their lives, said Dr Joseph Ravenell, an associate Professor of Population Health and Medicine at NYU Langone Health in New York. “If we’re able to achieve essentially the same mortality benefit but avoid patients having to be on medications for a lifetime, I can’t see that as being anything but positive – both from a quality of life standpoint as well as from a health economic standpoint,” he said. Many beta-blockers are generally affordable, but that can add up over a lifetime. Worldwide, a number of doctors are changing their approach to prescribing beta-blockers for heart attack survivors in the long term, said Dr Valentin Fuster, president of Mount Sinai Fuster Heart Hospital and general director of Spain’s Centro Nacional de Investigaciones Cardiovasculares. “In the past decade or so, some people, including myself, have questioned the role of beta-blockers in patients with good ventricular function,” he said. “On a broader scale, a change in practice is already happening and I think people will be more cautious in giving beta-blockers to those patients.” Recent studies in The New England Journal of Medicine showed that starting beta-blockers soon after a heart attack did not improve major outcomes for certain patients with normal heart pumping function. Despite this, many patients who are stable years after a heart attack continue taking beta-blockers. A key remaining question is whether stopping beta-blockers is safe for these stable patients. Now, a new study adds yet another layer to the conversation. Among low-risk adults who were in stable condition for at least a year after a heart attack, those who stopped taking beta-blockers did not face a higher risk of death, heart attack or hospitalisation for heart failure than those who stayed on the medication, according to the findings, published in The New England Journal of Medicine. The study was also presented at the American College of Cardiology’s annual scientific session in New Orleans. “In real-world practice, many patients stay on beta-blockers for years after a heart attack,” the study’s lead author Dr Joo-Yong Hahn, Professor of Cardiology at Samsung Medical Centre in Seoul. “Our trial directly tests a practical question clinicians face every day: in stable patients who have done well for years, do we really need to continue beta-blockers indefinitely, or can we safely consider stopping them?” ‘May not be necessary’ for all The study included data on more than 2 500 adults, at 25 health centres in South Korea, who were in stable condition after having a heart attack. With a median age of 63, they had been receiving beta-blocker therapy for at least one year, with many taking either carvedilol, bisoprolol or nebivolol. They were identified to enrol in the study between 2021 and 2023, and many had had heart attacks several years ago, Hahn said. About half of them were randomly assigned to stop taking beta-blockers, while the others continued their medications. The researchers watched them closely for about three years and examined how many had a recurrent heart attack, were hospitalised for heart failure, or died from any cause. Overall, recurrent heart attack, hospitalisation for heart failure or death from any cause occurred among 58 of those (or 7.2%) in the discontinuation group, compared with 74 (or 9%) in the continuation group. “In stable low-risk patients who have been taking the medication for years after a heart attack, stopping beta-blockers was just as safe as continuing them for death, another heart attack or hospitalisation for heart failure,” Hahn said. Specifically, deaths from any cause occurred in 2.4% of the discontinuation group versus 3.4% in the continuation group; recurrent heart attacks occurred in 2.3% versus 2.6%, respectively; and hospitalisations for heart failure occurred in about 2% of each group. Blood pressure and heart rate appeared to increase among those who discontinued beta-blockers, the researchers noted, but the group’s average systolic blood pressure stayed below 130. Systolic blood pressure is the top number in a blood pressure reading, and high blood pressure is considered to be 130/80 or higher. The researchers noted that because the study was conducted in South Korea, more research is needed to determine whether similar findings would emerge in other countries, including the United States. The study also raises the question of exactly when might be optimal to discontinue beta-blockers, and that could vary by patient. While the study does not suggest all heart attack survivors should stop beta blockers at one year, “I do think it can change practice in a meaningful way: it supports the idea that for appropriately selected stable patients without heart failure or left ventricular systolic dysfunction, routine lifelong beta-blockers may not be necessary,” Hahn said. “In practise, discontinuation can be considered with shared decision-making and monitoring, especially if a patient has beta-blocker-related side effects.”   CNN article – After a heart attack, beta-blockers are often a lifelong medicine. Maybe they shouldn’t be (Open access)   See more from MedicalBrief archives:   Risks of stopping beta-blockers after heart attack – French trial   Beta blockers have positive effect in pulmonary arterial hypertension   No benefits from 'outdated' beta-blockers after heart attack