Beta-blocker therapy and all-cause mortality after a coronary event: A matched nested case-control study using the Victorian Cardiac Outcomes Registry linked data

AIMS: Beta-blocker therapy has traditionally been recommended following coronary events based on clinical trials involving patients with systolic dysfunction. Its survival benefit in patients with preserved left ventricular ejection fraction (LVEF), is being re-examined. This study assessed the association of beta-blocker therapy prescription and all-cause mortality following a coronary event and percutaneous coronary intervention (PCI), stratified by LVEF. METHODS AND RESULTS: A state-wide nested case-control study of data from the Victorian Cardiac Outcomes Registry linked to the Australian National Death Index (2014-2022) was conducted. Adults discharged alive after PCI were stratified by LVEF: preserved (≥50%), mildly reduced (45-49%), moderately reduced (35-44%), and severely reduced (<35%). Propensity score matching and logistic regression models with cluster-robust standard errors were used to assess associations. Sensitivity analyses evaluated missing LVEF data and cardiovascular mortality at 30-days. Among 71,053 patients, 67.3% received beta-blockers. After matching, beta-blocker therapy was associated with higher odds of all-cause mortality in patients with preserved (OR 1.46, 95% CI 1.29-1.65) and mildly reduced LVEF (OR 1.48, 95% CI 1.15-1.91), with no significant benefit in moderately or severely reduced LVEF. Subgroup analyses confirmed higher odds of mortality for these LVEF groups in several clinical contexts. Sensitivity analyses supported primary findings. CONCLUSION: Beta-blocker therapy was associated with increased all-cause mortality in patients with preserved and mildly reduced LVEF, with no clear benefit in those with lower LVEF. These real-world findings support recent trials and challenge the routine prescription of beta-blocker therapy post-MI, highlighting the need for individualised treatment.