Metoprolol vs Bisoprolol for Atrial Fibrillation
Both metoprolol and bisoprolol are equally acceptable beta-blockers for rate control in atrial fibrillation, with guidelines listing them interchangeably without preference, though bisoprolol may offer superior quality of life outcomes in patients with concurrent heart failure.
Guideline-Based Recommendations
General Rate Control Strategy
Beta-blockers are recommended as first-line agents for rate control in atrial fibrillation, particularly for patients with preserved left ventricular ejection fraction (LVEF ≥40%) 1.
The 2003 American Academy of Family Physicians/American College of Physicians guidelines specifically list atenolol and metoprolol (along with diltiazem and verapamil) as recommended agents for rate control during both exercise and rest 1.
The 2016 European Society of Cardiology guidelines recommend beta-blockers, digoxin, diltiazem, or verapamil for rate control in AF patients with LVEF ≥40%, without distinguishing between specific beta-blockers 1.
Heart Failure Considerations
For patients with reduced ejection fraction (LVEF <40%), the recommended beta-blockers are bisoprolol, carvedilol, long-acting metoprolol, and nebivolol 1.
Beta-blockers and/or digoxin are specifically recommended to control heart rate in AF patients with LVEF <40% 1.
In patients with obstructive pulmonary disease, beta-1 selective blockers (such as bisoprolol) in small doses should be considered as an alternative for ventricular rate control 1.
Evidence Comparing the Two Agents
Quality of Life Data
The RATE-AF trial (2020) directly compared digoxin versus bisoprolol in 160 patients with permanent AF and heart failure, finding no significant difference in the primary quality of life outcome at 6 months 2.
However, digoxin showed significantly better symptom improvement (53% vs 9% with 2-class EHRA improvement, p<0.001) and fewer adverse events (25% vs 64%, p<0.001) compared to bisoprolol 2.
A 2025 South Asian study confirmed digoxin resulted in significantly greater quality of life improvement compared to bisoprolol (mean QoL score: 76.68 vs 70.90; p=0.004) in patients with permanent AF and heart failure 3.
Rhythm Maintenance
Metoprolol CR/XL demonstrated efficacy in maintaining sinus rhythm after cardioversion of persistent atrial fibrillation, with 48.7% relapse rate versus 59.9% with placebo (p=0.005) 4.
Metoprolol also provided better heart rate control during AF relapse (98 vs 107 beats/min with placebo) 4.
Clinical Decision Algorithm
For Patients with Preserved LVEF (≥40%)
Start with either metoprolol or bisoprolol as both are guideline-recommended and equally effective for rate control 1.
If rate control is inadequate with monotherapy, add digoxin or switch to a non-dihydropyridine calcium channel blocker (diltiazem or verapamil) 5.
For Patients with Reduced LVEF (<40%)
Prefer bisoprolol, carvedilol, long-acting metoprolol, or nebivolol as these are the evidence-based beta-blockers for heart failure 1.
If symptoms persist despite beta-blocker therapy, add digoxin for combination rate control 5.
Consider that digoxin may provide superior quality of life outcomes in this population based on recent comparative data 2, 3.
For Patients with Pulmonary Disease
Use beta-1 selective agents (bisoprolol preferred) in small doses rather than non-selective beta-blockers 1.
Non-dihydropyridine calcium channel antagonists (diltiazem or verapamil) remain the preferred alternative if beta-blockers are not tolerated 1.
Important Clinical Caveats
Anticoagulation must be maintained regardless of rate control strategy, based on stroke risk assessment 5.
Beta-blockers carry very low proarrhythmic risk compared to class I antiarrhythmic drugs, making them safer first-line options 6.
Recent evidence questions whether beta-blockers should remain the preferred rate-control therapy in all AF patients, suggesting the need for individualized selection 7.
Combination therapy with different rate-controlling agents should be considered if monotherapy fails to achieve target heart rate 1, 5.
For rhythm control strategies when rate control fails, consider class IC antiarrhythmics (flecainide or propafenone) in patients without structural heart disease, or electrical cardioversion for symptomatic patients 5.