A 58-year-old with HFrEF is currently on atenolol for hypertension. His cardiologist plans to switch him to a beta-blocker with proven mortality reduction in heart failure. Which agent should be chosen?
- A Propranolol
- B Atenolol at a higher dose
- C Metoprolol succinate ✓
- D Esmolol
Correct answer: C. Metoprolol succinate
Explanation
Only bisoprolol, carvedilol, and sustained-release metoprolol succinate have large randomized trial evidence (CIBIS-II, COPERNICUS, MERIT-HF) showing mortality reduction in HFrEF. Atenolol lacks such evidence and should be replaced with metoprolol succinate once the patient is compensated. Propranolol is never preferred in HFrEF, and esmolol is an ultra-short IV agent for acute settings, not chronic therapy. Beta-blockers must be started at low doses in stable patients only.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.