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Beta-1 Selective Adrenoceptor Blocker (Cardioselective Beta-Blocker)

Atenolol

Brand names: Tenormin

Adult dose

Dose: Hypertension: 25–50 mg once daily; max 100 mg/day. Angina: 100 mg once daily (or 50 mg twice daily). AF rate control: 50–100 mg once daily. Post-MI: 50 mg within 12 hours then 50 mg 12 hourly
Route: Oral (also IV available for arrhythmias/MI: 5 mg over 5 min, repeat if needed)
Frequency: Once daily (most indications)

Clinical pearls

  • Atenolol is no longer first-line for uncomplicated hypertension (NICE NG133 — beta-blockers now fourth-line unless compelling indication)
  • Remains important post-MI, angina, AF rate control, and heart failure with reduced ejection fraction (HFrEF)
  • Beta-1 selectivity at low doses — reduced risk of bronchospasm vs. non-selective beta-blockers (nadolol, propranolol), but still use with great caution in asthma/COPD
  • Renal elimination — dose reduction required in severe renal impairment (eGFR <15)
  • Never stop abruptly in angina or post-MI — wean gradually (rebound tachycardia/ischaemia)
  • NICE NG185 (ACS): beta-blockers continued long-term post-STEMI

Contraindications

  • Asthma / bronchospasm (beta-1 selective but risk in severe asthma)
  • Second or third degree AV block (without pacemaker)
  • Sick sinus syndrome
  • Cardiogenic shock
  • Severe peripheral arterial disease
  • Uncontrolled heart failure

Side effects

  • Bradycardia
  • Fatigue, lethargy (very common)
  • Cold extremities
  • Sexual dysfunction (erectile dysfunction)
  • Bronchospasm (in susceptible individuals)
  • Hypoglycaemia masking (caution in insulin-treated diabetics)
  • Worsening psoriasis

Interactions

  • Calcium channel blockers (diltiazem, verapamil) — profound bradycardia/AV block; avoid combination
  • Clonidine — rebound hypertension if clonidine stopped while on beta-blocker
  • Digoxin — additive bradycardia
  • NSAIDs — reduced antihypertensive effect
  • Insulin/oral hypoglycaemics — hypoglycaemia symptoms masked

Monitoring

  • Blood pressure and heart rate
  • ECG (PR interval)
  • Symptoms of peripheral arterial disease or Raynaud's
  • Blood glucose in diabetics
  • eGFR (dose adjust if needed)

Reference: BNF; NICE NG133 (Hypertension in adults, 2019 updated 2023); NICE NG185 (ACS, 2020); ESC/ESH Hypertension Guidelines (2023); https://bnf.nice.org.uk/drugs/atenolol/. Verify against your local formulary and the latest BNF before prescribing.

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