A landmark NEJM trial just challenged four decades of post-heart-attack dogma
When “keep taking it” stops being the right answer
Beta-blockers after a myocardial infarction have been a near-universal reflex for the better part of four decades. The evidence that justified it was built in an era before modern reperfusion, before high-intensity statins, before dual antiplatelet therapy and yet the prescription has persisted, largely unchallenged, in patients who stopped needing it.
The SMART-DECISION trial, published March 30, 2026, in the New England Journal of Medicine and simultaneously presented at the ACC 2026 Scientific Session, is the first randomized controlled trial to demonstrate that stopping beta-blockers after MI is noninferior to continuing them (in the right patient).
In appropriately selected patients who survived a heart attack and do not have heart failure or left ventricular systolic dysfunction, routine continuation of beta-blockers indefinitely may not be necessary.
— Joo-Yong Hahn, MD, PhD, Senior Investigator
The patient profile matters: LVEF ≥40%, no heart failure, stable for at least one year on therapy. That describes a sizable chunk of the post-MI population walking through retail and ambulatory pharmacy every single day.
What the numbers actually say
Conducted across 25 centers in South Korea, SMART-DECISION enrolled 2,540 patients (mean age 63.2 years, 12.8% women) from April 2021 to April 2023. Patients were randomized 1:1 and instructed to stop beta-blockers immediately or continue at the same dose. The primary composite endpoint: all-cause mortality, recurrent MI, or hospitalization for heart failure.
Key Outcomes at Median Follow-up
| Primary composite (discontinue) | 7.2% |
| Primary composite (continue) | 9.0% |
| Hazard ratio (95% CI) | 0.80 (0.57–1.13) |
| All-cause mortality — discontinue | 2.4% |
| All-cause mortality — continue | 3.4% |
| Recurrent MI — discontinue | 2.3% |
| Serious adverse events — discontinue | 11.5% |
| Serious adverse events — continue | 13.4% |
| Noninferiority margin (HR upper CI) | 1.4 |
Secondary endpoints, including new-onset atrial fibrillation, changes in LV function, and quality-of-life measures, were similarly comparable across groups. The noninferiority threshold was met. Discontinuation was not associated with worse outcomes by any pre-specified measure.
Important Caveats to Know
- Single-country trial (South Korea); generalizability to diverse populations is not yet established.
- Women represented only 12.8% of the cohort. Subgroup data hinted at possible benefit from continuation in women (HR 1.95), though the confidence intervals were wide.
- The ABYSS trial (France, NEJM 2024) failed to show noninferiority of discontinuation; the two trials used different populations and timeframes. SMART-DECISION patients stopped beta-blockers nearly 4.7 years post-MI vs. 2.9 years in ABYSS.
- Senior investigator Hahn’s own words: “This is not definitive. We need more evidence.”
Deprescribing as a clinical skill, not a gap in care
For pharmacists, this trial is less about a drug being removed and more about where deprescribing conversations now have data behind them. Post-MI patients on beta-blockers who have preserved LV function and no HF are common in every practice setting (community, hospital, ambulatory, MTM platforms).
Before SMART-DECISION, discontinuing a beta-blocker in this population felt like going off-guideline. Now there’s a randomized, noninferiority signal from a top-tier journal. That changes the calculus in structured medication reviews, IVIG MTM sessions, and transitions-of-care conversations.
The key phrase from the investigators: “discontinuation can be considered through shared decision-making and with monitoring of blood pressure and heart rate.” That’s a pharmacist role by definition.
The deprescribing movement is gaining real clinical footing
SMART-DECISION doesn’t exist in isolation. It follows a broader shift in cardiovascular medicine toward questioning indefinite therapies in low-risk, stable patients. From aspirin in primary prevention to ACE inhibitors in preserved EF, the field is actively interrogating whether “start and never stop” was ever the right default.
For pharmacy as a profession, this trend is an expansion of scope dressed in evidence. Deprescribing protocols, medication burden assessments, and polypharmacy management are increasingly recognized as value-generating clinical services, not just pill counting in reverse. SMART-DECISION gives one more high-profile, data-backed entry point into that conversation.
Watch for potential guideline updates from ACC/AHA in the coming cycle. The existing recommendation for indefinite beta-blocker therapy post-MI was built before the modern reperfusion era. The evidence base that justified it is now being systematically dismantled.
Bottom Line
For stable post-MI patients with preserved ejection fraction and no heart failure, beta-blocker discontinuation after at least one year of therapy is a clinically reasonable conversation to have, not a deviation from standard of care. SMART-DECISION provides the first randomized, non-inferiority evidence to back it. Pharmacists are positioned to initiate that conversation, frame it with data, and support patients and prescribers through the decision. That is the job. This is the evidence.
Sources
1. Choi KH, Kang D, Kim W, et al. Discontinuation of beta-blocker therapy after myocardial infarction. N Engl J Med. 2026;394(13):1302–1312. doi:10.1056/NEJMoa2601005
2. American College of Cardiology. SMART-DECISION: Discontinuing beta-blockers safe 1 year post MI for stable patients. ACC.26 Late-Breaking Clinical Trial. March 30, 2026.
3. TCTMD. SMART-DECISION: Stopping beta-blockers post-MI safe in stable patients. Published March 30, 2026.
4. Medscape. Stable patients may safely end beta-blockers post-MI: SMART-DECISION. Published April 9, 2026.
5. PACE-CME. Discontinuation of long-term beta-blockers in post-MI patients with LVEF ≥40% does not change clinical outcomes. April 14, 2026.
6. Medical Dialogues. Beta-blockers discontinuation safe after one year in selected patients after MI: SMART-DECISION trial. April 7, 2026.
