More than 1 in 5 Americans between 60 and 79 take a beta-blocker regularly, often prescribed after a heart attack, sometimes years or even decades before. For most of that time, the prevailing assumption was that staying on the medication was simply the safer choice. Two major trials published in 2025 and 2026 have made that assumption considerably harder to defend, raising serious questions about heart drug elderly risks that cardiologists are now being pressed to address.
Beta-blockers work by blocking the effects of adrenaline on the heart, slowing the heart rate and reducing blood pressure. Drugs like metoprolol, bisoprolol, and carvedilol have been prescribed after heart attacks since the 1980s, backed by trial data showing they reduced deaths in patients whose hearts were pumping weakly. The patients in those original trials looked very different from the typical heart attack survivor today. They were treated before routine stenting, before modern cholesterol-lowering drugs, and before the now-standard invasive care that most patients receive. The medicine has moved on. The prescribing habits, in many cases, have not.
Millions of older adults are taking a medication whose evidence base was built in a different era of cardiology. Two large randomized trials now put that habit directly under the microscope.
What the REBOOT Trial Found
Beta-blockers have long been a foundational treatment after acute heart attack, but the supporting evidence was derived from trials that predated modern standards of care, before routine stenting, invasive management, potent antiplatelet drugs, and statins. The REBOOT trial, published in the New England Journal of Medicine in 2025, was designed to address that gap directly.
The trial found that beta-blocker therapy following a heart attack in patients with mildly reduced or preserved ejection fraction above 40% did not reduce the incidence of death from any cause, reinfarction, or hospitalization for heart failure. It randomized approximately 8,000 patients from 109 centers across Spain and Italy.
Ejection fraction measures how much blood the heart pumps out with each beat. An ejection fraction below 40% means the heart is pumping weakly; between 40% and 50% indicates slightly impaired pumping; and above 50% means the heart is pumping normally, though there may still be problems with the ventricle stiffening. The patients in REBOOT had hearts that were working reasonably well, yet they were still being routinely placed on beta-blockers, a practice the trial’s results now question.
At the same European Society of Cardiology Congress 2025, a second trial called BETAMI-DANBLOCK found that beta-blockers did lower the risk of death or major adverse cardiac events in post-heart attack patients with ejection fraction above 40%, producing apparently conflicting results. Both research groups said a coherent message emerged from the two trials, pointing to subgroup analyses and an updated meta-analysis that found a benefit of beta-blockers specifically in post-heart attack patients with mildly reduced ejection fraction between 40% and 49%. For patients whose hearts were pumping at full or near-full capacity, the benefit was far less clear.
For women in the REBOOT trial, the data suggested something more troubling than simply no benefit. The trial enrolled patients over 18 discharged after a heart attack with ejection fraction above 40% who had received invasive management during their hospital stay, and patients were randomized at discharge to either receive or not receive beta-blockers. Among women in that randomized group, a 2025 analysis in the European Heart Journal found an incidence rate of 30.4 events per 1,000 patient-years in those taking beta-blockers, compared to 21.0 per 1,000 patient-years in those who were not, a hazard ratio of 1.45, meaning women on beta-blockers faced roughly 45% higher risk of death, reinfarction, or heart failure hospitalization.
When Stopping May Be Safer Than Continuing
The REBOOT data asked whether beta-blockers should be started after certain types of heart attack. A separate 2026 trial asked a different but equally pressing question: for patients who’ve already been on these drugs for a year or more, is it safe to stop?
The SMART-DECISION trial, published simultaneously in the New England Journal of Medicine, is the first randomized study to demonstrate the noninferiority of beta-blocker discontinuation in post-heart attack patients without left ventricular systolic dysfunction or heart failure, according to Joo Yong Hahn, MD, PhD, chair of cardiology at Samsung Medical Center in Seoul, South Korea, who presented findings at the American College of Cardiology Scientific Session 2026.
In stabilized patients after a heart attack who had no heart failure or left ventricular systolic dysfunction, discontinuing beta-blockers after one year was a reasonable option. Stopping therapy showed similar outcomes to continuation, including all-cause death, recurrent heart attack, or heart failure hospitalization, at 7.2% versus 9.0%.
The 2,540 patients enrolled had been receiving beta-blockers for at least one year after their heart attack, with a median follow-up of 3.1 years. Many had been on these medications for the better part of a decade with no formal reassessment of whether they still needed them.
As Dr. Hahn put it, 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.
The Specific Risks in Older Adults
Even when a medication isn’t helping, it may still be actively causing harm, and that calculus shifts significantly with age. Beta-blockers carry a side effect profile that lands harder in older bodies than in younger ones, for reasons rooted in how aging changes cardiovascular physiology.
According to the NIH’s drug information resource, stopping beta-blockers may benefit some older adults because the drugs can exacerbate chronotropic incompetence (the heart’s inability to raise its rate appropriately during exercise), worsen cardiac output, and reduce exercise tolerance. Beta-blockers are also a common cause of adverse drug reactions and can worsen function in some older adults, and they contribute to fatigue and sexual dysfunction.
The numbers on specific side effects are stark. A study published in American Family Physician found that beta-blocker therapy increased the absolute annual risk of bradycardia (abnormally slow heart rate) in 38 per 1,000 patients, and increased the annual risk of dizziness in 57 per 1,000 patients. For a 70-year-old already managing balance issues, fatigue, or blood pressure instability, either of those figures represents a meaningful added burden.
A 2017 study in BMC Geriatrics examining older adults with high blood pressure reached a pointed conclusion: compared to other antihypertensive drugs, beta-blockers were associated with a higher risk of a composite endpoint of death, stroke, or heart attack, showed no benefit over other antihypertensives or placebo regarding mortality, and appeared to be less effective than other drug classes in reducing cardiovascular events.
For nursing home residents, the functional impact is documented. A 2017 study in PMC found that among older nursing home residents after a heart attack, beta-blocker users were more likely than non-users to experience functional decline, with a number needed to harm of 52, meaning for every 52 patients taking the drug, one experienced measurable loss of physical function who would not have otherwise.
Age-related physiological changes make the problem worse. Older adults often have lower cardiac output, pre-existing bradycardia, high total peripheral resistance, reduced renal blood flow, and low plasma renin activity. These are the very conditions that beta-blockers can worsen, which is why the risk-benefit equation looks different at 72 than it did at 55.
The Question of Deprescribing
There’s a term clinicians use for the deliberate process of stopping or reducing medications when the risks outweigh the benefits: deprescribing. A 2019 paper in the Journal of the American College of Cardiology defines it as the process of medication withdrawal to reduce unnecessary or potentially harmful use under health supervision, and notes that the average follow-up duration in 30 secondary prevention trials examining beta-blockers was only around three years, far shorter than the decades some patients stay on the drug.
The growing interest in beta-blocker deprescribing has now reached the clinical trial stage. The DEPRESCRIBE-HFpEF trial, which began enrollment in February 2026 at Weill Cornell Medicine, is specifically designed to determine the evidence for removing inessential beta-blockers in older adults with heart failure with preserved ejection fraction (HFpEF).
Stopping beta-blockers is not something patients should do abruptly on their own. Abrupt cessation of beta-blockers can lead to a rebound phenomenon of angina, anxiety, severe hypertension, tachycardia, and can cause a heart attack. Any reduction needs to happen gradually, under medical supervision, with the dose tapered down over time.
If you or an older relative is taking multiple medications after a cardiac event, it may be worth discussing the full prescription list with a cardiologist. Research on polypharmacy and medication burden in older adults has grown alongside this deprescribing movement, and the two questions are closely related.
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What This Means for You
The first trial to demonstrate the safety of discontinuing beta-blockers in stable post-heart attack patients is, by its own authors’ admission, only a starting point. More evidence is still needed. The picture is not one of beta-blockers being harmful across the board. The evidence supporting beta-blockers after a heart attack remains strong in patients with significantly reduced ventricular function, defined as ejection fraction at or below 40%. The drug works when the heart is genuinely weakened. The controversy is specifically about patients whose hearts are pumping at or near normal capacity.
Among U.S. adults aged 60 to 79, beta-blockers are taken by 22.3% of the population, making them one of the most commonly used drug classes in that age group, according to the CDC. That’s a large number of people for whom the risk-benefit calculation may deserve a second look, particularly those who had a heart attack years ago, have no heart failure, and have never had a conversation with their doctor about whether the prescription still makes sense.
If you or someone you know fits that description, the question worth raising at the next cardiology appointment is straightforward: given current evidence, and given my current heart function and overall health, is there a reason to continue this medication? For some patients, the answer will still be yes. For others, the most recent evidence suggests it may not be.
The distinction matters and, for older adults managing side effects that erode daily function and quality of life, so does asking for it.
Disclaimer: The author is not a licensed medical professional. The information provided is for general informational and educational purposes only and is based on research from publicly available, reputable sources. It is not intended to constitute, and should not be relied upon as, medical advice, diagnosis, or treatment. Always consult a licensed physician or other qualified healthcare provider regarding any medical condition, symptoms, or medications. Do not disregard, avoid, or delay seeking professional medical advice or treatment because of information contained herein.
AI Disclaimer: This article was created with the assistance of AI tools and reviewed by a human editor.
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