Can atenolol (beta blocker) be used in Heart Failure (HF)?

From the Guidelines

Atenolol is not recommended for use in heart failure (HF). While beta-blockers are a cornerstone of heart failure treatment, only specific beta-blockers have been proven beneficial in clinical trials, namely carvedilol, metoprolol succinate, and bisoprolol, as stated in the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. Atenolol lacks the evidence base for heart failure treatment and may actually worsen outcomes in these patients. It is a cardioselective beta-blocker that primarily reduces heart rate and blood pressure but doesn't provide the same beneficial effects on cardiac remodeling and mortality reduction that the guideline-recommended beta-blockers do.

The approved beta-blockers for heart failure work by blocking harmful neurohormonal activation, reducing ventricular remodeling, and improving left ventricular function over time. Key benefits of these beta-blockers include:

• Reducing the risk of death and the combined risk of death or hospitalization, as seen in patients with or without coronary artery disease and in patients with or without diabetes mellitus 1
• Lessening the symptoms of HF, improving the patient’s clinical status, and enhancing the patient’s overall sense of well-being 1
• Providing favorable effects in patients with or without CAD and in patients with or without diabetes mellitus, as well as in women and blacks 1

If a patient with heart failure requires beta-blocker therapy, they should be started on low doses of carvedilol, metoprolol succinate, or bisoprolol with gradual uptitration to target doses as tolerated, while monitoring for signs of worsening heart failure, bradycardia, or hypotension. This approach is supported by the 2013 ACCF/AHA guideline for the management of heart failure, which recommends the use of one of the three beta blockers proven to reduce mortality (eg, bisoprolol, carvedilol, and sustained-release metoprolol succinate) for all patients with current or prior symptoms of HFrEF, unless contraindicated, to reduce morbidity and mortality 1.

From the FDA Drug Label

CONTRAINDICATIONS Atenolol tablets are contraindicated in sinus bradycardia, heart block greater than first degree, cardiogenic shock, and overt cardiac failure. WARNINGS Cardiac Failure Sympathetic stimulation is necessary in supporting circulatory function in congestive heart failure, and beta blockade carries the potential hazard of further depressing myocardial contractility and precipitating more severe failure

Atenolol is contraindicated in overt cardiac failure.

• The drug label explicitly states that atenolol is contraindicated in overt cardiac failure 2.
• Additionally, the label warns that beta blockade can precipitate more severe failure in patients with congestive heart failure 2.
• Therefore, atenolol should not be used in patients with heart failure (HF).

From the Research

Atenolol in Heart Failure

• Atenolol is a beta-blocker that has been studied in the context of heart failure (HF) treatment 3.
• The study found that atenolol, when added to high-dose enalapril, provided substantial benefits in patients with advanced left ventricular dysfunction, including reduced worsening heart failure and death 3.
• However, other beta-blockers such as bisoprolol, metoprolol succinate, and carvedilol have been more extensively studied and proven to reduce mortality and hospitalization in patients with Class II to IV heart failure 4, 5, 6, 7.
• The choice of beta-blocker is important, as benefit is not a class-effect, and atenolol may not be as effective as other beta-blockers in certain patient populations 4.

Comparison with Other Beta-Blockers

• Atenolol is a selective beta-1 blocker, but it may not be as effective as other beta-blockers such as bisoprolol, metoprolol succinate, and carvedilol, which have been shown to have greater benefits in reducing mortality and hospitalization in patients with heart failure 4, 5, 6, 7.
• A study comparing bisoprolol, carvedilol, and metoprolol succinate found that all three beta-blockers had similar effects on mortality amongst patients with chronic heart failure, but atenolol was not included in this study 7.
• Another study found that metoprolol succinate is associated with significant mortality and morbidity benefits in the treatment of heart failure, but atenolol was not compared directly with metoprolol succinate in this study 6.

Adverse Reactions and Considerations

• Beta-blockers, including atenolol, can have adverse reactions such as metabolic disturbance, bronchospasm, and epinephrine/hypertensive interaction, particularly in patients with certain comorbidities or concomitant medications 4.
• The possession of beta-2 blockade, particularly if combined with alpha-blockade, is associated with an increased occurrence of sexual dysfunction, but atenolol is a selective beta-1 blocker and may not have this effect 4.
• Lipophilic beta-blockers like propranolol and metoprolol appear in high concentrations in human brain tissue and are associated with side-effects such as insomnia, dreams, and nightmares, but atenolol is hydrophilic and may not have this effect 4.