Beta-Blockers After PCI for Stable Coronary Artery Disease and Preserved Left Ventricular Ejection Fraction.

Summary

In a propensity-matched emulation of a target trial, early beta-blocker initiation after PCI for stable CAD with preserved LVEF was associated with higher all-cause mortality and no reduction in MI, stroke, HF, or AF hospitalizations over 5 years. Hypotension-related admissions were more frequent with beta-blockers.

Key Findings

• Early beta-blocker initiation was associated with higher all-cause mortality (HR 1.11) over 5 years.
• No significant differences in hospitalizations for MI, stroke, HF, or AF/flutter between groups.
• Higher hospitalization for hypotension with beta-blockers (HR 1.10); falsification endpoints showed no spurious associations.
• Results were consistent across multiple sensitivity analyses.

Clinical Implications

Avoid routine early beta-blocker initiation after PCI in stable CAD with preserved LVEF; reserve for clear indications (e.g., arrhythmias, angina not controlled by other agents) and monitor for hypotension.

Limitations

• Observational design; potential residual confounding and misclassification of indications/adherence
• Lack of granular data on dose-titration and symptom burden influencing prescribing

Future Directions

Randomized trials or high-quality pragmatic trials targeting this population; subgroup analyses (e.g., ischemia burden, arrhythmia) to refine indications.