New international studies show that beta-blockers – a long-trusted heart medicine that many doctors have quietly dropped for certain patients in recent years – can still save lives after a heart attack. The findings overturn years of uncertainty and reopen a debate that has long divided cardiologists.
When 58-year-old Jens was discharged from the hospital after a heart attack, he felt enormous relief. The operation had gone well, and his heart was pumping almost normally again. But one thing puzzled him: the doctor sent him home without beta-blockers – the very drug that for decades had been considered a cornerstone of heart treatment.
The explanation was simple but unsettling: the effect was thought to be small, the side-effects many. In recent years, hospitals across the world have gradually scaled back their use of beta-blockers after heart attacks – although not all have agreed. The uneven practice reflects a deeper, unresolved disagreement among cardiologists about which patients truly benefit.
Jens is a fictional patient, used to illustrate a common clinical dilemma: in many hospitals, beta-blockers have gradually been phased out after a heart attack. Yet this is far from universal practice – and the difference reflects a deep, ongoing divide among cardiologists.
For years, doctors in cardiac units around the world have debated how to treat the growing group of patients who recover well after a heart attack but whose hearts still pump slightly less efficiently than normal.
Some cardiologists continue to rely on the evidence from the 1980s and 1990s, when beta-blockers clearly reduced mortality. Others argue that medicine has moved on – today’s patients are treated faster, live healthier lives and are less likely to suffer permanent heart damage.
The result has been inconsistent practice. Some hospitals continue prescribing beta-blockers as a matter of routine, whereas others have stopped altogether.
Several countries – same conclusion
A series of new international studies – including the Danish-Norwegian BETAMI-DANBLOCK trial, led in Denmark by Eva Prescott from Bispebjerg Hospital – now provides a much clearer answer as to whether beta-blockers still have a place in treatment.
The study was published alongside three contemporary trials from Spain, Sweden and Japan. All four examined the same question: do beta-blockers still make a difference for heart-attack patients who do not have severe heart failure?
The aim was to determine whether this decades-old therapy still offers independent protection in a modern clinical setting in which patients already receive rapid interventions and state-of-the-art drug treatment. The trials were designed for a shared meta-analysis and cover diverse health systems and clinical practices – enabling their results to be compared and generalised across countries.
The combined analysis showed that beta-blockers significantly reduce the risk of death, recurrent heart attack and heart failure among patients whose hearts pump only slightly below normal.
“We began the study assuming that beta-blockers probably no longer made much difference, because today’s patients have such good prognoses,” explains Eva Prescott. “So we were genuinely surprised to see the effect so clearly. It’s an important result because it shows that a large group of patients can still benefit from a treatment that was already being phased out in Denmark.”
A realistic picture of treatment
The studies do not have to be read as one collective result – each also tells its own story.
The Danish–Norwegian BETAMI–DANBLOCK trial was among the largest and most comprehensive and was published in the New England Journal of Medicine. In total, 5,700 patients from 25 hospitals in Denmark and 19 in Norway took part. All were recruited shortly after their heart attack and randomly assigned either to receive beta-blockers or not. Both groups received modern standard therapy, including blood thinners, cholesterol-lowering medication and ACE inhibitors, and were followed for several years to see who developed new heart attacks or heart failure or died.
Both doctors and patients knew who received medication and who did not, but the results were analysed according to the original randomisation – the principle known as intention-to-treat, which reflects how a treatment works in real-world practice when doctors choose to prescribe beta-blockers or not.
When research mirrors reality
The researchers deliberately designed the trial to resemble everyday clinical conditions. They included older patients and those with multiple diseases – people who are often excluded from conventional clinical trials. That, says Eva Prescott, makes the results both more credible and more applicable to real life.
The REBOOT study in Spain, which enrolled more than 8,000 patients, was also published in the New England Journal of Medicine. It found no overall benefit from beta-blockers – but, as Prescott points out, most of the participants in Spain had better heart function. When the subgroup with mildly reduced pumping ability was examined separately, the pattern matched the Scandinavian findings.
The smaller CAPITAL-RCT study in Japan, published in Circulation, included patients with varying levels of heart function and again showed a benefit among those with mildly reduced pump function. By contrast, the study in Sweden – which only included patients with normal heart function – found no measurable effect.
Finally, a joint meta-analysis combining all four trials was published simultaneously in The Lancet, reinforcing the overall picture.
The heart’s pumping power decides the effect
The studies point to a clear conclusion: the benefit of beta-blockers depends largely on how well the heart pumps. To distinguish between patient groups, researchers measure how efficiently the heart empties itself of blood.
This pumping ability is expressed as the ejection fraction – the percentage of blood in the left ventricle that is expelled with each heartbeat. A value above 50% is considered normal; between 40% and 49% means that the heart is pumping slightly less efficiently.
Beta-blockers had a positive effect only among patients with this mildly reduced function – those with an ejection fraction between 40% and 49%. People with lower values are already recommended this treatment, while those whose hearts pump normally do not appear to benefit. The Danish-Norwegian results confirmed this pattern.
Eva Prescott and colleagues are now preparing an extended meta-analysis, to be presented at the upcoming American Heart Association Scientific Sessions 2025, to determine whether patients with completely normal pump function obtain any real advantage from beta-blockers. Preliminary data suggest that the effect is minimal – a finding the forthcoming analysis is expected to confirm.
Old drug, new insight
If these results stand, they could alter clinical practice. In the longer term, the hope is that many patients can avoid unnecessary medication, whereas others can receive treatment that genuinely saves lives.
Eva Prescott estimates that roughly one in four patients discharged after a heart attack have mildly reduced pumping function – and these are precisely the people who stand to gain from targeted use of beta-blockers. “It’s about giving the medicine to those who truly benefit,” she says.
She adds that the study also carries a broader message: breakthroughs do not always depend on new and costly drugs. “Sometimes it’s simply about using the old ones better.”
When foundations make a difference
However, she also points out that this type of research is difficult to carry out, precisely because there is no financial interest in finding answers to these kinds of questions from the industry.
Whereas industry-sponsored studies typically have around a billion Danish kroner to play with, she and her colleagues have had to fight to scrape together the 10 million Danish kroner it cost to finance this study.
This is just enough to cover the costs of including patients from individual hospitals in the study. This was achieved thanks to support from the Danish Heart Foundation, the Novo Nordisk Foundation and others and with the voluntary participation of doctors throughout Scandinavia.
“We have done this for very little money and without industrial support, and yet it can lead to a significantly better prognosis – with fewer hospitalisations, fewer cases of heart failure and heart attacks and fewer deaths. It really makes sense,” concludes Eva Prescott.
