What is the best course of action for a patient currently on atenolol (beta blocker) for blood pressure management?

Atenolol for Blood Pressure Management: Current Evidence and Recommendations

Beta-blockers, including atenolol, are not recommended as first-line agents for hypertension unless the patient has compelling indications such as ischemic heart disease, heart failure with reduced ejection fraction, or requires heart rate control. 1

Current Guideline Position on Atenolol

The most recent 2024 ESC guidelines and 2017 ACC/AHA guidelines are clear and consistent: beta-blockers should be reserved for patients with specific cardiovascular indications, not used as primary therapy for uncomplicated hypertension. 1

First-Line Agents (NOT Beta-Blockers)

For most patients with hypertension, the following drug classes have demonstrated superior cardiovascular outcomes and are recommended as first-line therapy: 1

• ACE inhibitors or ARBs
• Dihydropyridine calcium channel blockers (amlodipine, nifedipine LA, felodipine)
• Thiazide or thiazide-like diuretics (chlorthalidone, indapamide)

Combination therapy with two of these agents (preferably as a single-pill combination) is recommended as initial treatment for most patients with confirmed hypertension (BP ≥140/90 mmHg). 1, 2

Specific Concerns with Atenolol

Evidence Against Atenolol as First-Line Therapy

The 2017 ACC/AHA guidelines explicitly state: "The beta blocker atenolol should not be used because it is less effective than placebo in reducing cardiovascular events." 1

A landmark 2004 meta-analysis found that despite lowering blood pressure, atenolol showed: 3

• No reduction in all-cause mortality compared to placebo (RR 1.01)
• No reduction in cardiovascular mortality (RR 0.99)
• No reduction in myocardial infarction (RR 0.99)
• Higher mortality when compared to other antihypertensives (RR 1.13, p<0.05)

Dialyzability Issues

In patients on hemodialysis, atenolol's high dialyzability is problematic. Nondialyzable beta-blockers (like propranolol) may be preferred over highly dialyzable ones (like atenolol) to maintain intradialytic protection against arrhythmias. 1 However, if atenolol is used in dialysis patients, 25-50 mg should be administered after each dialysis session under hospital supervision due to risk of marked blood pressure drops. 4

When Beta-Blockers ARE Appropriate

Beta-blockers should be combined with other major BP-lowering drug classes when there are compelling indications: 1

• Post-myocardial infarction (continue for at least 3 years, possibly longer) 1
• Stable angina pectoris 1
• Heart failure with reduced ejection fraction (HFrEF) - though carvedilol or metoprolol succinate are preferred over atenolol 1
• Heart rate control in atrial fibrillation 1

Recommended Management Algorithm

For Patients Currently on Atenolol Without Compelling Indications:

1. Assess for compelling indications (prior MI, angina, HFrEF, rate control needs) 1

2. If NO compelling indications exist:

   • Transition to guideline-directed first-line therapy: 1, 2
     • Start with ACE inhibitor or ARB + dihydropyridine CCB OR
     • ACE inhibitor or ARB + thiazide/thiazide-like diuretic
   • Use single-pill combination when possible to improve adherence 1, 2
   • Do not abruptly discontinue atenolol - taper gradually while initiating new therapy 1

3. If compelling indications exist:

   • Continue beta-blocker therapy but consider switching to more evidence-based agents: 1
     • Metoprolol succinate (once daily, preferred for post-MI and HFrEF)
     • Carvedilol (preferred for HFrEF)
     • Bisoprolol (cardioselective, once daily)
   • Add first-line agents (ACE inhibitor/ARB + CCB or diuretic) to achieve BP target 1

Blood Pressure Targets:

• General target: 120-129 mmHg systolic if tolerated 1, 2
• With stable ischemic heart disease: <130/80 mmHg 1
• With chronic kidney disease: 120-129 mmHg systolic 2
• If target cannot be achieved or poorly tolerated: as low as reasonably achievable 1, 2

Specific Dosing Considerations for Atenolol (If Continued)

For elderly or renally-impaired patients, dose adjustment is mandatory: 4

• Creatinine clearance 15-35 mL/min: Maximum 50 mg daily
• Creatinine clearance <15 mL/min: Maximum 25 mg daily
• Hemodialysis patients: 25-50 mg after each dialysis session under supervision 4

Standard dosing in patients with normal renal function: 25-100 mg twice daily 1

Critical Pitfalls to Avoid

• Do not use atenolol as monotherapy for uncomplicated hypertension - it lacks cardiovascular outcome benefit compared to other agents 3
• Do not abruptly discontinue atenolol - taper gradually to avoid rebound hypertension and increased cardiovascular risk 1, 4
• Do not combine two RAS blockers (ACE inhibitor + ARB) when transitioning therapy 1
• Do not use atenolol in patients with reactive airway disease - choose cardioselective agents if beta-blockade is required 1
• Do not ignore renal function - atenolol is renally excreted and requires dose adjustment 4

Bottom Line

Unless your patient has a compelling indication (post-MI, angina, HFrEF, rate control), atenolol should be replaced with evidence-based first-line combination therapy consisting of an ACE inhibitor or ARB plus either a dihydropyridine CCB or thiazide-like diuretic. 1, 2, 3 This approach provides superior cardiovascular protection and mortality reduction compared to beta-blocker monotherapy.