Abrupt Atenolol Withdrawal and ECG Changes in POTS
Yes, abruptly stopping atenolol can contribute to your ECG findings, though the sinus rhythm at 83 bpm with borderline QTc and anterior T-wave inversion likely represents a combination of withdrawal effects and your underlying POTS physiology rather than a dangerous rebound phenomenon.
Understanding Beta-Blocker Withdrawal in Your Context
The FDA label for atenolol explicitly warns that "patients with coronary artery disease, who are being treated with atenolol, should be advised against abrupt discontinuation of therapy" and notes that "severe exacerbation of angina and the occurrence of myocardial infarction and ventricular arrhythmias have been reported" 1. However, this warning primarily applies to patients with coronary artery disease, not POTS patients.
What the Evidence Shows About Atenolol Withdrawal
Atenolol has a more benign withdrawal profile than other beta-blockers: Research specifically examining abrupt atenolol withdrawal in patients with severe stable angina found no serious coronary events during 144 hours post-withdrawal, with only gradual increases in heart rate and minor clinical consequences 2.
The withdrawal timeline is gradual, not abrupt: When atenolol was stopped after long-term therapy (19 months average), blood pressure and heart rate returned to baseline gradually over a period that "greatly exceeded the time for elimination of atenolol," with no evidence of rebound hypertension or increased cardiac adrenergic sensitivity 3.
Your heart rate of 83 bpm is actually reasonable: In POTS patients, atenolol works by blunting the excessive sympathetic response 4. Your current heart rate suggests partial return of your baseline POTS physiology rather than dangerous rebound tachycardia.
Interpreting Your Specific ECG Findings
The Sinus Rhythm at 83 bpm
This represents your underlying POTS returning: POTS is characterized by excessive heart rate increases (≥30 bpm or >120 bpm) upon standing, not necessarily elevated resting heart rates 5, 6.
83 bpm at rest is not concerning: This is within normal range and far from the tachycardia that would indicate a dangerous withdrawal syndrome 2.
The Borderline QTc
Atenolol withdrawal does not typically cause QT prolongation: The research on atenolol withdrawal focused on heart rate and blood pressure changes, not QT interval effects 2, 3.
This finding warrants attention but is not an emergency: Borderline QTc can occur in POTS patients independent of medication changes and should be monitored, but does not represent acute withdrawal danger 5.
The Anterior T-Wave Inversions
T-wave changes can reflect autonomic dysfunction in POTS: The excessive sympathetic activity characteristic of POTS can produce ECG changes including T-wave abnormalities 5, 6.
These are not specific markers of atenolol withdrawal: The studies examining atenolol cessation did not report T-wave inversions as withdrawal phenomena 2, 3.
Critical Distinction: You Don't Have Coronary Disease
The FDA warning about atenolol withdrawal applies primarily to patients with coronary artery disease, not POTS patients 1. The mechanism of concern—unmasking of underlying ischemia—is not relevant to your condition unless you have concurrent coronary disease.
What You Should Do Now
Immediate Actions
Monitor your orthostatic symptoms: Track your heart rate response when standing (measure supine, then after 2,5, and 10 minutes of standing) to assess if your POTS symptoms are returning 5.
Watch for concerning symptoms: Seek immediate care if you develop chest pain, syncope, sustained palpitations, or heart rates consistently >120 bpm at rest 1.
Hydration and salt loading: Increase fluid intake to 2-3 liters daily and salt intake to 10-12 grams daily to counteract the hypovolemia component of POTS 5, 6.
Follow-Up Considerations
The ECG changes need evaluation but are not emergent: Your anterior T-wave inversions and borderline QTc should be assessed in context of your clinical presentation, but do not represent acute danger from withdrawal 7.
Consider gradual atenolol taper if restarting: If symptoms become intolerable, the FDA recommends that "when discontinuation of atenolol is planned, the patients should be carefully observed and advised to limit physical activity to a minimum" 1.
Common Pitfalls to Avoid
Don't assume all beta-blocker withdrawal is the same: The dangerous "beta-blocker withdrawal syndrome" has occurred "almost exclusively in patients taking propranolol, many of whom had unstable angina at the time of withdrawal," not with atenolol in stable patients 2.
Don't restart atenolol without addressing why it was stopped: If the hospital discontinued it for a specific reason (hypotension, bradycardia, etc.), that issue needs resolution first 1.
Don't ignore the possibility of concurrent cardiac pathology: While your symptoms likely reflect POTS physiology, the anterior T-wave inversions warrant evaluation to exclude structural heart disease 7.
Timeline Expectations
Based on the pharmacology of atenolol withdrawal, you can expect:
Days 1-5: Gradual increase in resting heart rate and return of orthostatic symptoms 2, 3.
Days 5-10: Peak return of baseline POTS physiology, with maximal orthostatic tachycardia 2.
Beyond 2 weeks: Stabilization at your pre-treatment baseline, assuming no other interventions 3.
Your ECG findings at 83 bpm suggest you are in the early-to-mid withdrawal phase, experiencing return of your underlying POTS rather than a dangerous rebound phenomenon.