What is the preferred choice between Atenolol (Metoprolol) and Metoprolol (Lopressor) for a typical adult patient with hypertension or at risk of cardiovascular events?

Metoprolol is Preferred Over Atenolol for Hypertension

For typical adult patients with hypertension or at risk of cardiovascular events, metoprolol (particularly metoprolol succinate) should be chosen over atenolol due to questioned cardiovascular benefits of atenolol and superior 24-hour blood pressure control with metoprolol. 1

Key Guideline Recommendations

The American Heart Association explicitly recommends metoprolol over atenolol for hypertension treatment based on concerns about atenolol's cardiovascular efficacy 1. Both agents are cardioselective beta-1 blockers, but critical differences exist in their clinical performance and outcomes 2.

Beta-Blockers as Second-Line Agents

Beta-blockers are not recommended as first-line antihypertensive agents unless the patient has ischemic heart disease or heart failure 2, 1. This is a crucial consideration—if your patient lacks these compelling indications, consider ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics first 2.

Specific Clinical Scenarios

For Heart Failure with Reduced Ejection Fraction (HFrEF)

Metoprolol succinate is specifically preferred in patients with HFrEF, along with bisoprolol and carvedilol 2, 1. The MERIT-HF trial demonstrated a 34% reduction in mortality with metoprolol succinate in heart failure patients 2. If your patient has both hypertension and HFrEF, metoprolol succinate is the clear choice 1.

For Standard Hypertension Management

When beta-blocker therapy is indicated for hypertension:

• Metoprolol tartrate: 100-200 mg twice daily 2, 1
• Metoprolol succinate: 50-200 mg once daily 2, 1
• Atenolol: 25-100 mg twice daily 2

Evidence Supporting Metoprolol Superiority

24-Hour Blood Pressure Control

Research demonstrates that metoprolol succinate provides superior 24-hour blood pressure control compared to atenolol 3. In a randomized trial, early morning systolic BP (the highest cardiovascular risk period) decreased by 7 mm Hg with metoprolol succinate versus an increase of 3 mm Hg with atenolol (P=0.03) 3. Overall 24-hour systolic BP reduction was 9 mm Hg with metoprolol versus only 1 mm Hg with atenolol (P=0.03) 3.

Duration of Action Concerns

Atenolol's shorter duration of action is problematic for once-daily dosing 4. Studies show atenolol is less effective 25 hours after dosing compared to metoprolol, suggesting inadequate 24-hour coverage with once-daily administration 4. This may explain why atenolol-based therapies have shown inferior outcomes in clinical trials 5.

Cardiovascular Outcomes

Meta-analyses have questioned atenolol's cardiovascular benefits, showing no effect on all-cause mortality, cardiovascular mortality, or myocardial infarction compared to placebo 5. Atenolol demonstrated higher total mortality and stroke risk compared with other antihypertensive agents 5.

Formulation Selection

Choose metoprolol succinate (extended-release) over metoprolol tartrate (immediate-release) when possible 1. Metoprolol succinate allows once-daily dosing with sustained 24-hour coverage, improving adherence and blood pressure control throughout the circadian cycle 2.

Special Populations

Bronchospastic Airway Disease

Both atenolol and metoprolol are cardioselective, making them preferred over non-selective beta-blockers in patients with bronchospastic disease who require beta-blocker therapy 2, 1. However, start with low doses and monitor closely 1.

Ischemic Heart Disease

For patients with both hypertension and coronary artery disease, metoprolol succinate, bisoprolol, or carvedilol are preferred agents with proven mortality benefits 2.

Critical Safety Considerations

Never abruptly discontinue either beta-blocker—taper gradually to avoid rebound hypertension, tachycardia, or precipitation of acute coronary events 2, 1. This is particularly important in patients with ischemic heart disease 2.

Common Pitfalls to Avoid

• Don't use atenolol once daily expecting 24-hour control—the pharmacokinetics don't support this, and twice-daily dosing may be necessary 4
• Don't choose beta-blockers as first-line therapy unless compelling indications (heart failure, post-MI, angina) exist 2
• Don't assume all beta-blockers are equivalent—metoprolol succinate, bisoprolol, carvedilol, and nebivolol have proven mortality benefits in heart failure, while atenolol does not 2, 1

Practical Algorithm

1. Does the patient have HFrEF? → Choose metoprolol succinate 2, 1
2. Does the patient have ischemic heart disease or post-MI? → Choose metoprolol succinate, bisoprolol, or carvedilol 2
3. Is this for uncomplicated hypertension? → Consider other first-line agents first; if beta-blocker needed, choose metoprolol succinate over atenolol 2, 1
4. Dose metoprolol succinate 50-200 mg once daily 2, 1