Atenolol Has Limited Evidence and Is Not Recommended for Heart Failure Management
Atenolol is not among the evidence-based beta-blockers proven to reduce mortality in heart failure, and current guidelines recommend using only bisoprolol, carvedilol, or metoprolol succinate instead. 1
Why Atenolol Is Not Guideline-Recommended
The major heart failure trials that established beta-blocker mortality benefit specifically studied metoprolol, bisoprolol, bucindolol, and carvedilol—but not atenolol. 1 These evidence-based beta-blockers demonstrated:
- 30% reduction in all-cause mortality 1
- 40% reduction in hospitalizations 1
- 34-38% decrease in cardiovascular mortality 1
Atenolol lacks this level of evidence. The FDA label for atenolol explicitly states it "can increase oxygen requirements by increasing left ventricular fiber length and end diastolic pressure, particularly in patients with heart failure." 2
The Three Evidence-Based Beta-Blockers You Should Use
Current guidelines from the American Heart Association, American College of Cardiology, and European Society of Cardiology recommend only these three beta-blockers for heart failure with reduced ejection fraction: 1, 3
- Bisoprolol: Start 1.25 mg daily, target 10 mg daily 1, 4
- Metoprolol succinate (extended-release): Start 12.5-25 mg daily, target 200 mg daily 1, 4
- Carvedilol: Start 3.125 mg twice daily, target 25-50 mg twice daily 1, 3, 4
Carvedilol may be preferred as first-line due to its unique α1, β1, and β2 receptor blockade, which provides superior blood pressure reduction and demonstrated 65% mortality reduction in trials. 3 The COMET trial showed carvedilol reduced mortality by 17% compared to metoprolol tartrate (short-acting form). 3
Limited Evidence for Atenolol
While small studies suggest atenolol may provide some benefit when added to high-dose ACE inhibitors, this evidence is weak:
- One trial (n=100) showed atenolol reduced worsening heart failure and death compared to placebo when added to enalapril 40 mg daily, but this was a small, single study. 5
- A comparative study (n=150) found metoprolol significantly more effective than atenolol, with metoprolol reducing combined endpoints by 71% versus atenolol's 53%. 6
- Another small study (n=25) showed atenolol improved ejection fraction but actually decreased peak oxygen consumption compared to controls. 7
These studies are insufficient to establish atenolol as guideline-directed therapy. 1
Critical Implementation Points
Initiate beta-blockers only in stable, euvolemic patients after optimizing diuretics and discontinuing intravenous inotropes. 1, 3 Starting beta-blockers during acute decompensation can worsen heart failure. 1
Titrate slowly over weeks to months, doubling the dose every 1-2 weeks as tolerated. 1, 3 Target the maximum evidence-based dose, as higher doses correlate with better outcomes. 8
If worsening symptoms occur during titration: 1, 3
- First increase diuretics
- Temporarily reduce (not discontinue) the beta-blocker dose
- Always attempt re-titration once stable
Contraindications include: 1, 3
- Asthma or severe bronchial disease
- Symptomatic bradycardia or hypotension
- Acute cocaine intoxication (though safe in patients with cocaine history who are not acutely intoxicated) 4
The Bottom Line
Use bisoprolol, metoprolol succinate, or carvedilol—not atenolol—for heart failure management. These three agents have robust mortality data from large randomized trials involving over 10,000 patients. 1 Atenolol lacks this evidence base and should not be considered equivalent to guideline-directed beta-blocker therapy. 1, 3