Metoprolol vs Propranolol

For hypertension and heart rate control, metoprolol and propranolol are similarly effective. Both lower blood pressure and reduce heart rate by blocking beta-1 receptors in the heart.

For heart failure, metoprolol succinate (extended-release) has strong evidence from the MERIT-HF trial showing a 34% reduction in mortality. Propranolol is not recommended for heart failure. For post-myocardial infarction, both drugs have demonstrated mortality benefits.

Propranolol is uniquely effective for certain conditions beyond cardiovascular disease: it is FDA-approved for migraine prophylaxis, essential tremor, and is widely used off-label for performance anxiety and situational anxiety due to its ability to block peripheral beta-2 receptors that mediate tremor and other physical anxiety symptoms.

Metoprolol's cardioselectivity means it primarily affects the heart, with less impact on the lungs and peripheral vasculature. This makes it safer for patients with mild asthma or COPD (though all beta-blockers should be used with caution in these populations).

Propranolol's non-selective beta-blockade can cause bronchospasm and is generally contraindicated in patients with asthma or significant reactive airway disease. It can also mask the symptoms of hypoglycemia (particularly tremor and tachycardia), which is a concern for patients with diabetes.

Common side effects shared by both include fatigue, dizziness, cold extremities, and bradycardia. Propranolol may cause more pronounced cold hands and feet due to beta-2 blockade in peripheral blood vessels. Both drugs can cause depression and sleep disturbances, though propranolol (being more lipophilic) crosses the blood-brain barrier more readily and may cause more vivid dreams.

Both metoprolol and propranolol are available as inexpensive generics. A 30-day supply of either drug typically costs $4-$15 at most pharmacies. Extended-release formulations (metoprolol succinate/Toprol-XL, propranolol ER/Inderal LA) may cost slightly more but are also available as generics.

Cost is generally not a distinguishing factor between these medications.

Metoprolol is available in immediate-release (tartrate, taken twice daily) and extended-release (succinate, taken once daily) formulations. Propranolol is also available as immediate-release (taken 2-4 times daily) and extended-release (taken once daily).

The extended-release formulations of both drugs allow once-daily dosing, improving convenience. Metoprolol tartrate should be taken with food to enhance absorption. Propranolol should be taken consistently with or without food.

For situational use (performance anxiety, acute tremor), propranolol immediate-release offers the advantage of as-needed dosing.

Metoprolol is generally preferred for hypertension, heart failure (succinate form), and post-MI care, particularly in patients with lung disease or diabetes. Its cardioselectivity provides a more targeted effect with fewer respiratory and metabolic concerns.

Propranolol is preferred for migraine prevention, essential tremor, performance anxiety, and conditions where beta-2 blockade is therapeutically useful. It may also be preferred for hyperthyroidism and portal hypertension (variceal bleeding prophylaxis).

Your healthcare provider will choose based on the specific condition being treated and your other medical conditions. Never stop a beta-blocker abruptly, as this can cause rebound hypertension and tachycardia.