After a heart attack, beta-blockers are often a lifelong medicine. Maybe they shouldn’t be

By Jacqueline Howard, CNN

(CNN) — For decades, surviving a heart attack has come with a lifelong prescription: Stay on medications called beta-blockers to help protect your heart. But doctors are taking a closer look at whether long-term beta-blocker use is really necessary, especially beyond the first year of recovery.

Beta-blockers are a class of prescription medications that can help lower blood pressure and slow heart rate, and they are commonly used to treat a wide range of cardiovascular concerns. Although they are generally considered safe, they may carry some side effects including fatigue, dizziness, dry mouth or eyes, or in rare cases sexual dysfunction.

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, and many people continue the medications for life. But a growing body of research has begun to question that approach.

Although each patient’s case is different, some doctors now argue that using beta-blockers for a year or two if needed rather than a lifetime could help people avoid unnecessary side effects and save money.

‘The evidence is changing’

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 beta-blockers 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 in patients who were having heart attacks 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 who had a heart attack,” Patel said.

Emerging research “may allow us, in real time, to start to de-escalate some of the therapies we have,” he said. “The evidence is changing, and it does look like for patients that are stable after having a heart attack, there’s more data on the risks and the benefits that look like 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,” Ravenell said.

Many beta-blockers are generally affordable, costing around $20 or less for a month supply, but that can add up over a lifetime.

“If you think about how much you spend per month on that, multiply that times a lifetime, then that’s one example of the potential cost savings,” he said. “And when we think about why patients often don’t comply with medication regimens, it’s usually because of side effects or because of costs, and so anything we can do to reduce the burden of pharmacotherapy on patients with chronic conditions, it’s a win.”

Some doctors around the world are already 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 last 10 to 15 years, some people – including myself – have questioned the role of beta-blockers in patients who had good heart or good ventricular function,” Fuster said.

On a broader scale, “I think a change in practice is going to happen. It’s already happening with the papers that we published recently,” he said. “I think people will be much more cautious in giving beta-blockers to patients who have good ventricular function.”

Recent studies in the New England Journal of Medicine previously 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 hospitalization for heart failure compared with those who stayed on the medication, according to a new study published Monday 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 Center in Seoul, said in an email. “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 new study included data on more than 2,500 adults, at 25 health centers in South Korea, who were in stable condition after having a heart attack. The adults, who had a median age of 63, had been receiving beta-blocker therapy for at least one year, with many of them taking either carvedilol, bisoprolol or nebivolol.

The adults were identified to enroll in the study between 2021 and 2023, and many had had heart attacks several years ago, Hahn said.

About half of the adults in the study were randomly assigned to stop taking beta-blockers, while the others continued their medications. The researchers watched each adult closely for about three years and examined how many had a recurrent heart attack, were hospitalized for heart failure or died from any cause.

Overall, recurrent heart attack, hospitalization for heart failure or death from any cause occurred among 58 adults (or 7.2%) in the discontinuation group, compared with 74 adults (or 9%) in the continuation group.

“In stable low-risk patients who have been taking beta-blockers for years after a heart attack, stopping beta-blockers was just as safe as continuing them for death, another heart attack or hospitalization 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 hospitalizations for heart failure occurred in about 2% of each group.

Blood pressure and heart rate appeared to increase among the adults 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 new 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 practice, discontinuation can be considered with shared decision-making and monitoring—especially if a patient has beta-blocker-related side effects.”

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