Should I stop atenolol given a resting heart rate of 47‑50 beats per minute while taking atenolol 25 mg every other day?

Should You Stop Atenolol with a Resting Heart Rate of 47-50 bpm?

No, do not stop atenolol abruptly—instead, reduce the dose by 50% (to 12.5 mg every other day) and monitor closely, as abrupt beta-blocker withdrawal can precipitate severe cardiovascular events including a 2.7-fold increase in mortality. 1

Immediate Assessment Required

Your resting heart rate of 47-50 bpm on atenolol 25 mg every other day requires evaluation for symptomatic bradycardia before any medication adjustment:

• Check for symptoms of hypoperfusion: dizziness, lightheadedness, syncope, near-syncope, fatigue, confusion, or chest discomfort 1
• Measure blood pressure: systolic BP <100 mmHg with symptoms is a contraindication to continued beta-blockade 1
• Assess for signs of heart failure: new or worsening dyspnea, peripheral edema, weight gain, or pulmonary rales 1
• Obtain a 12-lead ECG: rule out high-grade AV block (second or third-degree) which would mandate immediate discontinuation 1

Management Strategy Based on Symptoms

If You Are Asymptomatic (No Dizziness, Fatigue, or Hypotension)

Your heart rate of 47-50 bpm alone is NOT an absolute indication to stop atenolol if you have no symptoms and your blood pressure is adequate. 1

• Continue current dose if you have underlying coronary artery disease or heart failure, as beta-blockers provide mortality benefit even at lower heart rates 1
• Target resting heart rate for patients on beta-blockers is 50-60 bpm unless limiting side effects occur 1
• Monitor heart rate and blood pressure at each follow-up visit 1

If You Have Symptoms (Dizziness, Fatigue, or BP <100 mmHg)

Reduce atenolol dose by 50% rather than stopping completely:

• New dose: 12.5 mg every other day (half of your current 25 mg dose) 1
• Rationale: Maintaining some beta-blockade preserves cardiovascular protection while reducing bradycardic risk 1
• Monitor response: Check heart rate and blood pressure within 1-2 weeks after dose reduction 1

Critical Warnings About Abrupt Discontinuation

Never stop atenolol suddenly—this is a potentially life-threatening error:

• Abrupt withdrawal can cause severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias with 50% mortality in one study 1
• Beta-blocker withdrawal is associated with a 2.7-fold increased risk of 1-year mortality compared to continuous use 1
• Gradual tapering over 1-2 weeks is mandatory if discontinuation is necessary, reducing the dose by 25-50% every 1-2 weeks 1

When to Hold Atenolol Completely

Stop atenolol immediately only if:

• Symptomatic bradycardia with heart rate <50 bpm AND symptoms of hypoperfusion (altered mental status, chest pain, acute heart failure, shock) 1
• Systolic blood pressure <100 mmHg with symptoms of hypotension 1
• Second or third-degree AV block on ECG without a functioning pacemaker 1
• Acute decompensated heart failure with pulmonary edema or cardiogenic shock 1

Alternative Management Options

If dose reduction does not resolve symptomatic bradycardia:

• Consider switching to a different rate-control agent such as diltiazem 120-360 mg daily if you have atrial fibrillation 1
• Evaluate for drug interactions: digoxin, calcium channel blockers (diltiazem, verapamil), or amiodarone can cause additive bradycardia 1
• Rule out other causes: hypothyroidism, increased intracranial pressure, or infection can cause bradycardia independent of atenolol 1

Important Context About Atenolol

Atenolol is no longer recommended as first-line therapy for hypertension because it is less effective than placebo in reducing cardiovascular events 2. However, if you are taking it for:

• Angina pectoris: Other beta-blockers (metoprolol, carvedilol, bisoprolol) are preferred 2
• Post-myocardial infarction: Metoprolol succinate 200 mg daily is the evidence-based choice 1
• Atrial fibrillation rate control: Metoprolol or diltiazem are more effective options 1

Monitoring Protocol After Dose Adjustment

• Check heart rate and blood pressure every 4-6 hours initially, then at 1-2 weeks 1
• Watch for rebound hypertension (increase >20/10 mmHg) or tachycardia after dose reduction 1
• Assess for worsening angina or ischemic symptoms if you have coronary disease 1
• Consider cardiology referral if symptoms persist despite dose adjustment 1

Common Pitfalls to Avoid

• Do not assume bradycardia alone requires stopping atenolol—assess for symptoms and hemodynamic compromise first 1
• Do not abruptly discontinue without a gradual taper over 1-2 weeks 1
• Do not ignore other causes of bradycardia such as hypothyroidism or drug interactions 1
• Do not restart at full dose if you held atenolol—begin at 12.5 mg once daily and titrate slowly 1