Among patients without recorded heart failure characteristics, initiation of atenolol after myocardial infarction was associated with a lower risk of major adverse cardiovascular events, but not all-cause mortality, at 2 years compared with bisoprolol.
Key Findings
Results
Atenolol initiation after myocardial infarction was associated with a 2.9 percentage point lower risk of major adverse cardiovascular events compared with bisoprolol at 2 years.
Average treatment effect (ATE) for MACE was 2.9 percentage points (95% CI, 1.1–4.7) comparing atenolol to bisoprolol
Weighted proportions of patients experiencing MACE were 10.8% in the atenolol group and 14.1% in the bisoprolol group
MACE was a composite of cardiac arrest, all-cause mortality, reinfarction, stroke, or hospitalization for heart failure
Targeted maximum likelihood estimation was used to estimate average treatment effects
Outcomes were followed for up to 2 years following hospital discharge
Results
Atenolol initiation was not associated with a statistically significant difference in all-cause mortality compared with bisoprolol at 2 years.
ATE for all-cause mortality was 0.6 percentage points (95% CI, -0.2 to 1.3), with the confidence interval crossing zero
Weighted proportions of patients experiencing all-cause mortality were 1.4% in the atenolol group and 2.2% in the bisoprolol group
All-cause mortality was a prespecified secondary outcome
Results
Bisoprolol was the dominant beta-blocker prescribed at discharge, with atenolol used in a minority of patients.
Among 11,558 total eligible patients, 1,523 (13.2%) initiated atenolol and 10,035 (86.8%) initiated bisoprolol within 2 days of discharge
Study population was drawn from patients hospitalized in the Paris area between January 1, 2008, and December 31, 2018
Patients were required to be 18 years of age or older with a new myocardial infarction
Methods
The study population was specifically restricted to patients without prior heart failure, beta-blocker use, or loop diuretic use.
Patients prescribed beta-blockers or loop diuretics during the 2 years preceding hospital discharge were excluded
Patients with a recorded diagnosis of heart failure (based on ICD-10 codes) during the 2 years preceding hospital discharge were excluded
Data were sourced from the French National Health Data System (an administrative database)
The exclusion criteria were designed to identify patients 'without recorded characteristics in an administrative database suggesting the presence of heart failure'
Methods
Targeted maximum likelihood estimation was employed as the primary statistical method to adjust for confounding in this observational study.
The analysis estimated average treatment effects (ATEs) comparing patients initiated on atenolol versus bisoprolol
The study design was an observational cohort using administrative data, not a randomized trial
The study authors noted that the effect of different beta-blockers on outcomes of patients without heart failure after myocardial infarction is 'not well-studied'
What This Means
This research suggests that among heart attack survivors who did not have heart failure, those who were started on atenolol (a beta-blocker) at hospital discharge had a lower rate of major cardiovascular complications over the following two years compared to those started on bisoprolol (another commonly used beta-blocker). Specifically, about 10.8% of atenolol patients experienced a serious cardiovascular event (such as cardiac arrest, another heart attack, stroke, hospitalization for heart failure, or death) versus about 14.1% of bisoprolol patients. However, when looking at death from any cause alone, the difference between the two drugs was not statistically significant.
The study analyzed data from over 11,500 patients treated in the Paris area between 2008 and 2018, using French national health records. Because bisoprolol was used in about 87% of cases, atenolol represented a minority treatment choice. The researchers used advanced statistical methods to try to account for the fact that patients were not randomly assigned to one drug or the other — a key limitation of any observational study like this one.
This research matters because beta-blockers are routinely prescribed after heart attacks, yet there has been little direct comparison of different beta-blockers in patients who do not have heart failure. These findings raise the possibility that the choice of beta-blocker may influence patient outcomes, and may provide a basis for future randomized clinical trials to directly compare atenolol and bisoprolol in this specific patient population.
Laurenceau T, Meli U, Wang L, Chocron R, Cezard P, Menant E, et al.. (2026). Atenolol or Bisoprolol after Myocardial Infarction without Recorded Heart Failure.. NEJM evidence. https://doi.org/10.1056/EVIDoa2600138