Metoprolol is the most commonly prescribed beta blocker in the United States by a wide margin. In 2023, it accounted for nearly 60 million prescriptions filled for roughly 15 million patients, making it the sixth most prescribed drug of any kind in the country. Its dominance comes from a combination of versatility, low cost, and decades of clinical evidence supporting its use across several heart conditions.
Why Metoprolol Leads the Pack
Metoprolol is a cardioselective beta blocker, meaning it primarily targets the receptors on your heart rather than those in your lungs and blood vessels. This selectivity makes it a safer option for a broader range of patients compared to older, non-selective beta blockers like propranolol, which affect the whole body and carry a higher risk of breathing problems in people with lung conditions.
It also comes in two forms that serve different needs. The immediate-release version (metoprolol tartrate) is typically taken twice a day and is often used in hospital settings, particularly after a heart attack. The extended-release version (metoprolol succinate) is taken once daily, which makes it more convenient for long-term use. That once-a-day dosing is a practical reason many prescribers default to it: patients are more likely to stick with a medication they only have to remember once.
Cost plays a role too. Generic metoprolol tartrate runs about $0.20 per day, or roughly $6 for a 30-day supply. Generic atenolol, another commonly used beta blocker, is even cheaper at around $0.10 per day, but metoprolol’s wider range of approved uses keeps it in the top spot.
What Beta Blockers Are Prescribed For
Beta blockers work by slowing the heart rate, lowering blood pressure, and reducing how hard the heart muscle contracts with each beat. The net effect is that your heart needs less oxygen to do its job, which is why these drugs are so useful after a heart attack or during episodes of chest pain.
The main conditions beta blockers treat include:
- Heart failure: Metoprolol, bisoprolol, and carvedilol are the three beta blockers with the strongest evidence for improving survival in heart failure patients with reduced pumping function.
- Irregular heart rhythms: Beta blockers help control the heart rate in conditions like atrial fibrillation.
- Chest pain (angina): By lowering the heart’s workload, they reduce the frequency and severity of angina episodes.
- After a heart attack: Current guidelines from the American Heart Association recommend starting a low-dose beta blocker within 24 hours of a heart attack in most patients, then gradually increasing the dose.
- Migraines: Propranolol and metoprolol are both used to reduce the frequency of migraine attacks.
- Tremors: Propranolol is the most common choice for essential tremor.
One thing that surprises many people: beta blockers are not a first-line treatment for high blood pressure on its own. They’re typically added when other medications like diuretics or ACE inhibitors haven’t brought blood pressure down enough. They become a first choice only when there’s a second condition, like heart failure or a recent heart attack, that also benefits from the drug.
Other Commonly Prescribed Beta Blockers
While metoprolol dominates by prescription volume, several other beta blockers fill important roles. Atenolol was the go-to beta blocker for decades and is still widely used for blood pressure and angina, though its popularity has declined as evidence increasingly favored metoprolol and carvedilol for heart failure. Propranolol, the original beta blocker, remains the standard for performance anxiety, essential tremor, and migraine prevention. Because it’s non-selective, affecting receptors throughout the body, it’s more likely to cause side effects like cold hands and breathing difficulties.
Carvedilol occupies a unique niche. It blocks both beta receptors and alpha receptors, which means it relaxes blood vessels in addition to slowing the heart. This makes it particularly effective in heart failure but also means it can cause dizziness from blood pressure drops, especially when you first start taking it. Bisoprolol and nebivolol are newer, highly selective options that tend to cause fewer side effects, but they haven’t overtaken metoprolol in overall prescribing volume.
Common Side Effects
Beta blockers are generally well tolerated, but they do slow things down, and you can feel that. The most frequent complaint is fatigue or a sense of low energy, though a large analysis found that the actual increase in fatigue risk compared to a placebo was not statistically significant. What is real: about 38 out of every 1,000 patients on beta blockers develop a noticeably slow heart rate each year. For most people this is harmless, but if your resting pulse drops below 50 or you feel lightheaded, that’s worth mentioning to your prescriber.
Other commonly reported effects include cold fingers and toes (from reduced blood flow to the extremities), weight gain of a few pounds, and sexual dysfunction, particularly in men. These effects are generally more pronounced with non-selective beta blockers like propranolol and less common with cardioselective ones like metoprolol or bisoprolol.
People with asthma need to be cautious. Even cardioselective beta blockers can trigger airway tightening at higher doses, though the risk is much lower than with non-selective versions. Diabetes adds another layer of concern: beta blockers can mask the racing heart and trembling that normally warn you of low blood sugar, so if you’re on insulin or other glucose-lowering medications, more frequent blood sugar monitoring is a good idea.
What Starting Treatment Looks Like
If you’re prescribed metoprolol, expect to start at a low dose that gets adjusted over weeks. For high blood pressure, the extended-release version typically starts at 25 to 100 milligrams once daily. For heart failure, the starting dose is lower, usually 25 milligrams once a day (or 12.5 milligrams in severe cases), because the heart is already struggling and needs time to adjust.
One important rule with all beta blockers: never stop taking them abruptly. Suddenly cutting off a beta blocker can cause a rebound spike in heart rate and blood pressure, which in rare cases triggers chest pain or even a heart attack. If you need to stop, your prescriber will taper the dose gradually over one to two weeks.