Drug Comparisons

Beta-blockers relax blood vessels and slow down the heart to help it beat more regularly. These medications also help relax the tone of the heart to allow it to function more efficiently and protect the heart from harmful excessive stimulation. Beta-blockers have been used effectively in the treatment of coronary heart disease. The three types of coronary heart disease in which beta-blockers are primarily used are stable angina pectoris (chest pain with activity), unstable angina (chest pain at rest), and myocardial infarction (heart attack).

Drugs in this Class
Acebutolol (Sectral)
Metoprolol Extended-Release Tablets (Toprol-XL Extended-Release Tablets)
Propranolol ER (Betachron ER, Inderal LA, Innopran XL)
Atenolol (Tenormin)
Nadolol (Corgard)
Bisoprolol (Zebeta)
Metoprolol Tablets (Lopressor Tablets)
Pindolol (Visken)
Timolol Tablets ()
Propranolol (Inderal)
Atenolol Injection (Tenormin Injection)

Summarizing the Evidence

Stable Angina (Chest Pain with Activity)

• Oftentimes, stable angina can be controlled with lifestyle changes, an aspirin daily, and nitroglycerin that is dissolved under the tongue. If these measures do not control or prevent angina attacks, individuals may require maintenance therapy to prevent angina attacks, which includes beta-blockers. Beta-blockers are the preferred therapy and should be used in individuals if no contraindications exist.

• The Food and Drug Administration (FDA) has approved atenolol, metoprolol ER (extended release), metoprolol oral (immediate release), nadolol, propranolol oral (immediate release), and propranolol ER (extended release) for the treatment of chronic stable angina. Beta-blockers such as acebutolol, betaxolol, carteolol, nebivolol, penbutolol, and timolol do not have an FDA-approved indication for chronic stable angina. However, clinical studies comparing each of these drugs have shown that all beta-blockers are similar in their ability to prevent and treat symptoms associated with stable angina, such as chest pain and exercise intolerance. A recent study did show that people taking betaxolol once daily missed fewer doses and had a better quality of life than those taking metoprolol twice daily. The choice of which beta-blocker to use will typically depend upon other health conditions you may have, your doctor's preference, and/or your prescription benefits formulary.

Unstable Angina (Chest Pain at Rest)

• Unstable angina typically needs to be controlled with lifestyle changes, an aspirin daily, and nitroglycerin that is dissolved under the tongue. If these measures do not control or prevent angina attacks, individuals may require maintenance therapy to prevent angina attacks, which includes beta-blockers. Beta-blockers are the preferred therapy and should be used in individuals if no contraindications exist.

• There is little clinical evidence to suggest that one beta-blocker is superior to all others. Each beta-blocker is similar in its ability to prevent and treat unstable angina. Thus, the choice of which beta-blocker to use will depend upon other health conditions you may have, your doctor's preference, and/or your prescription benefits formulary.

Myocardial Infarction (Heart Attack)

• The American College of Cardiology and American Heart Association guidelines for treatment of a heart attack recommend that heart attack patients should receive beta-blockers unless contraindicated (meaning, the patient has some reason that he/she should not take the beta-blocker such as a severe allergy or reaction to the beta-blocker or a medical condition in which the use of a beta-blocker would be unsafe). No specific beta-blocker is named within the recommendations.

• The FDA has approved atenolol, metoprolol oral (immediate release), metoprolol ER (extended release), propranolol oral (immediate release), propranolol ER (extended release), and timolol for treatment following a heart attack. Clinical studies have shown that each of these beta-blockers reduces the incidence of illness and death when given after a heart attack. Acebutolol is not FDA-approved for treating heart attacks but has also been shown in clinical studies to reduce the incidence of illness and death when given after a heart attack. The effectiveness of nadolol, nebivolol, and bisoprolol in treating heart attacks has not been fully established due to a lack of clinical trials. Regardless of FDA-approval, any of the above beta-blockers can be used to treat a heart attack and the choice of which to use will typically depend upon other health conditions you may have, your doctor's preference, and/or your prescription benefits formulary.

• Not all beta-blockers should be used to treat a heart attack. Beta-blockers that should be avoided for treating heart attacks include carteolol, penbutolol, and pindolol. These beta-blockers have not been shown to reduce illness and death when given after a heart attack and have been shown in a few studies to possibly increase the risk for illness and death after a heart attack.

• Beta-blockers are generally well tolerated with mild side effects. In the past, beta-blockers were thought to be not as well tolerated as other drugs used to treat high blood pressure, however new studies have shown that they are better tolerated than previously thought. Common side effects of beta-blockers include fatigue, dizziness, depression, low blood pressure and slowed pulse. Nebivolol may be better tolerated than the other beta blockers.

Dosing and Administration

• There are a number of beta-blockers available that can be taken once daily. These include atenolol, bisoprolol, carteolol, metoprolol ER (extended release), nadolol, nebivolol, penbutolol, and propranolol ER (extended release). Acebutolol is often taken once or twice daily. Beta-blockers that require multiple doses throughout the day include metoprolol oral (immediate release), pindolol, propranolol oral (immediate release), and timolol.

Generic Availability

• Not all beta-blockers are currently available in generic formulations. Nebivolol and penbutolol are not available as a generic. All other beta-blockers have generic equivalents.

Drug Interactions

Some interactions between medications can be more severe than others. The best way for you to avoid harmful interactions is to tell your doctor and/or pharmacist what medications you are currently taking, including any over-the-counter products, vitamins, and herbals. For specific information on how the drugs interact and the severity of the interaction, please use our Drug Interactions Checker.

Side Effects

To view specific side effect information, please use our Side Effect Checker.

Additional Information

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4. Prida XE, Hill JA, Feldman RL. Systemic and coronary hemodynamic effects of combined alpha- and beta-adrenergic blockade (labetalol) in normotensive patients with stable angina pectoris and positive exercise stress test responses. Am J Cardiol 1987;59:1084-8.
5. de Muinck ED, Buchner-Moell D, van de Ven LL, and Lie KI. Comparison of the safety and efficacy of bisoprolol versus atenolol in stable exercise-induced angina pectoris: a Multicenter International Randomized Study of Angina Pectoris (MIRSA). J Cardiovasc Pharmacol. 1992;19(6):870-5.
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8. OROS with atenolol in the treatment of effort angina pectoris: a randomized double-blind study. Int J Clin Pharmacol Ther Tox. 1991;29(4):139-43.
9. Kostis JB. Comparison of the duration of action of atenolol and nadolol for treatment of angina pectoris. Am J Cardiol. 1988;62(17):1171-5.
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11. Narahara KA. Double-blind comparison of once daily betaxolol versus propranolol four times daily in stable angina pectoris. Betaxolol Investigators Group. Am J Cardiol. 1990;65(9):577-82.
12. Luther RR, Glassman HN, and Jordan DC. A comparison of carteolol and nadolol in the treatment of stable angina pectoris. J Clin Pharmacol. 1988;28(7):634-9.
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14. Frishman WH, Shapiro W, and Charlap S. Labetalol compared with propranolol in patients with both angina pectoris and systemic hypertension: a double-blind study. J Clin Pharmacol. 1989;29(6):504-11.
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21. Krumholz HM, Anderson JL, Brooks NH, et al. ACC/AHA Clinical Performance Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/ American Heart Association Task Force on Performance Measures. Journal of American College of Cardiology 2006; 47: 236-65.
22. Kardas P. Compliance, clinical outcome, and quality of life of patients with stable angina pectoris receiving once daily betaxolol versus twice daily metoprolol: a randomized controlled trial. Vasc Health Risk Manag 2007;3(2):235-42.
23. Wojciechowski D, Papademetriou V. Beta blockers in the management of hypertension: focus on nebivolol. Expert Rev Cardiovasc Ther 2008 Apr; 6(4):471-9.

Last Updated: May 2008
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