Metoprolol vs. Atenolol

See how Metoprolol and Atenolol compare on approved uses, dosing, side effects, and cost.

Key Takeaways

  • Metoprolol succinate is FDA-approved for heart failure, while atenolol is not, making it the better choice for patients who need a beta-blocker for both blood pressure and heart failure.

  • Both drugs are inexpensive generic beta-blockers, but metoprolol's extended-release form requires several titration steps while atenolol's dosing is simpler.

  • Atenolol is cleared by the kidneys and needs dose adjustment in renal impairment, while metoprolol is metabolized by the liver.

Metoprolol vs. Atenolol Drug Summary

Metoprolol

Metoprolol succinate is a beta-1 selective beta-blocker used to treat high blood pressure, angina, and stable heart failure. It comes as an extended-release tablet taken once a day, with the dose slowly increased over several weeks.

Atenolol

Atenolol is a beta-1 selective beta-blocker used to treat high blood pressure, angina, and stable patients recovering from a heart attack. It is taken as a standard oral tablet once daily, usually starting at a fixed dose with one step up if needed.

Metoprolol vs. Atenolol Side Effects

Metoprolol

Most common
hypotension (up to 27.4%)
bradycardia (up to 15.9%)
dizziness (about 10%)
tiredness (about 10%)

Atenolol

Most common
fatigue (up to 26%)
dizziness (up to 13%)
depression (up to 12%)
cold extremities (up to 12%)

Metoprolol vs. Atenolol Dosage

Metoprolol

Dosage
Dosage Table
STAGE DOSE WHEN
Starting dose 12.5 mg once daily Weeks 1-2
Maximum dose 400 mg once daily If needed
Dose changes 5 increases Every 2 weeks

Atenolol

Dosage
Dosage Table
STAGE DOSE WHEN
Starting dose 50 mg once daily At the start
Maximum dose 200 mg once daily If needed
Dose changes 2 increases As tolerated

Metoprolol vs. Atenolol Indications

Metoprolol

Metoprolol is FDA-approved for hypertension, angina, and stable heart failure across NYHA classes II through IV. It is also used off-label for atrial fibrillation rate control, migraine prevention, and essential tremor.

  • Hypertension

  • Angina pectoris

  • Heart failure (NYHA Class II-IV)

  • Off-label: atrial fibrillation rate control

  • Off-label: migraine prevention, essential tremor

Atenolol

Atenolol is FDA-approved for hypertension, angina, and use in hemodynamically stable patients after a heart attack. It is also used off-label for migraine prevention and tremor.

  • Hypertension

  • Angina pectoris

  • Acute myocardial infarction (stable patients)

  • Off-label: migraine prevention

  • Off-label: tremor

Metoprolol vs. Atenolol Pros and Cons

Metoprolol

Metoprolol's extended-release formulation and FDA approval for heart failure make it a versatile option for patients with overlapping cardiac conditions. It requires a multi-step titration schedule before reaching a maintenance dose.

Pros

  • FDA-approved for heart failure, not just blood pressure

  • Once-daily extended-release form smooths out blood levels

  • Metabolized by the liver, no renal dose adjustment needed

Cons

  • Requires several titration steps to reach maintenance dose

  • Not approved for acute decompensated heart failure or cardiogenic shock

  • Higher maximum maintenance dose may mean more pills at higher strengths

Atenolol

Atenolol offers a simpler dosing path with fewer titration steps, and it carries a specific approval for use after a heart attack. It is not approved for heart failure and needs dose adjustment in kidney disease.

Pros

  • Simpler dosing schedule with just one step-up

  • Specifically approved for use after a heart attack

  • Longer track record, approved by the FDA since 1981

Cons

  • Not approved for heart failure

  • Requires dose adjustment in patients with kidney impairment

  • Higher rate of fatigue reported than metoprolol's tiredness rate

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