Can atenolol (beta blocker) be used to treat performance anxiety disorder in patients with or without comorbid hypertension (high blood pressure) or other cardiovascular conditions?

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Last updated: February 4, 2026 • View editorial policy

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Use of Atenolol for Performance Anxiety Disorder

Atenolol should NOT be used for performance anxiety disorder; propranolol is the appropriate beta-blocker for this indication, with atenolol specifically contraindicated due to inferior cardiovascular outcomes and lack of evidence for anxiety disorders. 1

Why Atenolol is Inappropriate

Cardiovascular Guideline Contraindications

  • The ACC/AHA explicitly states that atenolol should not be used because it is less effective than placebo in reducing cardiovascular events 1
  • Multiple major hypertension guidelines specifically recommend avoiding atenolol due to inferior outcomes in randomized controlled trials (LIFE and ASCOT trials) 1
  • Atenolol has low beta-1 selectivity compared to other agents, which increases risk of bronchospasm in patients with reactive airway disease 1

Lack of Evidence for Performance Anxiety

  • While guidelines list "performance anxiety and anxiety disorders" as potential indications for beta-blockers as a drug class, atenolol is not specifically recommended for this indication 1
  • The limited research on atenolol for anxiety is preliminary observational data from military clinics, not rigorous controlled trials 2
  • One systematic review noted that benefits of beta-blockers (propranolol and atenolol) are "limited to performance anxiety," but this does not establish atenolol as preferred 3

The Correct Beta-Blocker: Propranolol

Evidence-Based Recommendations

  • Propranolol 20-40 mg taken 1 hour before the performance event is the established treatment for situational performance anxiety 4, 5
  • Propranolol blocks peripheral effects of adrenaline, reducing rapid heart rate, tremors, and nervousness during performance situations 4
  • Multiple guidelines from the American College of Cardiology and American College of Surgeons support propranolol specifically for performance anxiety and procedural tremor 4, 5

Clinical Algorithm for Performance Anxiety

For Isolated/Infrequent Performance Anxiety:

  • Screen for contraindications: asthma, COPD, bradycardia, heart block, heart failure 4, 5
  • Prescribe propranolol 20-40 mg to take 1 hour before the event 4
  • Advise trial dose before an important event to assess individual response and tolerability 4
  • Can combine with cognitive behavioral therapy and relaxation techniques 4

For Frequent/Chronic Performance Anxiety:

  • Consider cognitive behavioral therapy as first-line treatment 4
  • If pharmacotherapy needed chronically, use SSRIs/SNRIs, not beta-blockers 4
  • Canadian and Japanese guidelines deprecate propranolol for chronic social anxiety disorder 4

Important Contraindications and Precautions

  • Absolute contraindications: cardiogenic shock, sinus bradycardia, hypotension, heart block greater than first degree, heart failure, reactive airways disease 5
  • Use with caution in diabetes as propranolol may mask hypoglycemia symptoms 4, 5
  • Never abruptly discontinue after regular use due to risk of rebound symptoms and acute myocardial ischemia 5
  • Common side effects include bradycardia, hypotension, fatigue, cold extremities, and sleep disturbances 4

Critical Clinical Pitfalls

Why This Distinction Matters

  • Prescribing atenolol when propranolol is indicated exposes patients to a medication with documented inferior cardiovascular outcomes without established benefit for performance anxiety 1
  • The hydrophilic properties of atenolol (does not cross blood-brain barrier as readily) may theoretically reduce central effects, but this has not translated to proven efficacy for performance anxiety 1
  • If a patient has contraindications to propranolol (such as asthma), the solution is NOT to switch to atenolol, but rather to use alternative approaches like SSRIs/SNRIs or cognitive behavioral therapy 4

Special Populations

  • In patients with comorbid hypertension requiring beta-blocker therapy, use guideline-directed beta-blockers (carvedilol, metoprolol succinate, bisoprolol, nadolol) rather than atenolol 1
  • For patients with both cardiovascular disease and performance anxiety, propranolol can serve dual purposes when appropriate 4, 5

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

4
Guideline

Propranolol for Stage Fright

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

5
Guideline

Propranolol Indications and Usage

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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