Atenolol and Verapamil: Interaction Details
AI-assisted, pharmacist-reviewed · AI content regenerated Jul 15, 2026 · Source data updated Jul 11, 2026 · Sources: FDA labeling, DDInter 2.0, cited literature
Verapamil
Atenolol
How we grade severity & evidence
Severity levels
- Contraindicated: These should generally not be used together.
- Major: Potentially serious — often needs a change or close monitoring.
- Moderate: Can be significant — usually manageable with monitoring.
- Minor: Usually limited clinical impact.
Evidence grades
- Established: Well documented — supported by controlled studies or strong clinical data.
- Probable: Good supporting evidence, though not definitively proven.
- Suspected: Some evidence suggests this interaction, but it is not well established.
- Possible: Limited or conflicting evidence; the interaction may occur.
- Theoretical: Predicted from the drugs' pharmacology; not yet confirmed in people.
Ratings come from the documented interaction literature and are reviewed by a pharmacist. They describe the documented risk of the combination, not what will necessarily happen to you — your dose, timing, and health picture all matter.
Both verapamil and atenolol slow down your heart and lower your blood pressure. Verapamil is a calcium channel blocker, and atenolol is a beta blocker. When you take them together, those effects can stack up. That can make your heart beat too slowly (bradycardia), slow the electrical signals in your heart, and drop your blood pressure more than expected. You might feel dizzy, tired, or lightheaded.
This is a well-known combination, and doctors do prescribe both together on purpose in some cases. Please don't stop either one on your own. Your care team can manage this by checking your heart rate and blood pressure and adjusting your doses to fit you.
Additive negative chronotropic, dromotropic, and inotropic effects. Verapamil (a non-dihydropyridine CCB) and atenolol combine to depress AV nodal conduction, sinus rate, and myocardial contractility, raising the risk of bradycardia, AV block, hypotension, and heart failure. Verapamil may also reduce hepatic metabolism of some beta blockers, though atenolol is largely renally cleared, so the additive pharmacodynamic effect predominates here. Onset is rapid; evidence is probable; severity major.
- Risk amplified by LV dysfunction, aortic stenosis, or high doses.
- Monitor: heart rate, blood pressure, ECG (PR interval), signs of decompensation.
- Doses may need individualization; consider alternatives in high-risk patients.
What happens
An increased risk of hypotension, bradycardia and slow AV conduction
Interaction Deep Dive
Taking verapamil together with beta blockers depresses AV conduction and may heighten the likelihood of bradycardia1. Because both verapamil and beta blockers exert direct negative inotropic actions and slow AV conduction, their combination can potentially worsen hypotension, bradycardia, congestive heart failure, and conduction abnormalities10. Factors such as left ventricular dysfunction, aortic stenosis, or high doses of either agent raise the cardiac risk111213. This reaction has, on occasion, been documented with ophthalmic beta blockers14.
Why it happens (mechanism)
Additive cardiovascular effects, decreased metabolism of some beta blockers
How to manage this interaction
If your care team wants you on both, they can manage this safely.
- Keep taking both as prescribed unless your prescriber tells you otherwise.
- Your team may monitor your heart rate, blood pressure, and heart rhythm more closely, especially early on and if you have any heart weakness or a heart valve problem.
- Your doses may need to be adjusted and individualized by your care team.
- Tell your pharmacist or doctor if you feel dizzy, very tired, faint, short of breath, or notice a slow or irregular heartbeat.
Management is individual — confirm any change with your pharmacist or prescriber.
Literature reports
6 reports — tap to read
a) The adverse events seen when verapamil and a beta blocker are used together frequently involve conduction disturbances (9% of patients), dyspnea or heart failure (8% of patients), hypotension or dizziness (5% of patients), and lethargy (2% of patients). These cardiovascular adverse events resulted in discontinuation of therapy in 5% to 8% of patients receiving the combination. The pairing of intravenous verapamil with a beta blocker is contraindicated, and oral verapamil with a beta blocker should be reserved for patients whose left ventricular function is not impaired 2.
b) Pharmacodynamic interactions have been documented with propranolol, atenolol, metoprolol, and pindolol, with the greatest effects seen with propranolol 34. Such interactions are likely to arise with all beta blocking agents, especially in patients who are at risk.
c) Giving oral atenolol together with oral verapamil produced higher steady-state atenolol plasma concentrations in certain patients undergoing long-term oral maintenance treatment. In some of the ten patients enrolled in the study, the atenolol area under the concentration-time curve (AUC) rose by more than 100%. Nevertheless, the between-group comparisons did not reach statistical significance 4. An interaction with metoprolol has likewise been reported 5. No meaningful pharmacokinetic interaction was found between verapamil and propranolol 6.
d) In a randomized, crossover study, nine healthy volunteers were given single oral doses of R-verapamil 120 mg or placebo along with talinolol 50 mg. Administering R-verapamil concurrently reduced the maximum concentration (Cmax) of talinolol from 149 ng/mL to 95 ng/mL and also lowered the area under the concentration-time curve (AUC) from 0 to 24 hours from 945 ng/h/mL to 721 ng/h/mL. Talinolol renal clearance did not change. Verapamil undergoes extensive metabolism and is a substrate of both P-glycoprotein and cytochrome P450 3A isoenzymes. Talinolol is also a P-glycoprotein substrate. Verapamil's capacity to lower the oral bioavailability of talinolol is most likely dependent on dose 7.
e) A 72-year-old woman experienced intractable cardiogenic shock while receiving combined verapamil and atenolol treatment for recurrent supraventricular arrhythmia. She had coronary atherosclerosis, liver cirrhosis, and bradycardia-tachycardia syndrome. A pacemaker was placed and verapamil therapy was then started. Cardiogenic shock was precipitated when atenolol was added to her regimen two weeks after the implantation. An attempt to raise aortic pressure using high dose catecholamines and counterpulsation was unsuccessful. Aortic pressure rose immediately following intravenous administration of calcium chloride. The patient recovered and was discharged two weeks afterward 8.
f) Verapamil and beta-blockers both exert direct negative inotropic effects, slow AV conduction, and may potentiate hypotension, bradycardia, congestive heart failure, and conduction abnormalities 9.
Common questions
Can I take Atenolol and Verapamil together?
Taking verapamil and atenolol together can add up to a dangerously slow heart rate and low blood pressure, so your care team will monitor you and tailor your doses. Keep taking both as prescribed and report dizziness, fatigue, or a slow heartbeat. Always confirm with your pharmacist or prescriber before making any change.
How serious is the Atenolol and Verapamil interaction?
It is rated major. Potentially serious — often needs a change or close monitoring.
How quickly could this interaction happen?
The documented onset is "rapid". Effects can appear quickly, often within about 24 hours of combining the drugs.
How is the Atenolol and Verapamil interaction managed?
If your care team wants you on both, they can manage this safely. Keep taking both as prescribed unless your prescriber tells you otherwise. Your team may monitor your heart rate, blood pressure, and heart rhythm more closely, especially early on and if you have any heart weakness or a heart valve problem. Your doses may need to be adjusted and individualized by your care team. Tell your pharmacis… Management is individual — always follow your own care team's guidance.
How strong is the evidence for this interaction?
The evidence is graded "probable". Good supporting evidence, though not definitively proven.
From our Q&A
Real reader questions about these medications, each personally answered by our pharmacist:
Questions for your pharmacist
- Does my dose of Atenolol or Verapamil need adjusting while I take them together?
- What symptoms should prompt me to call you or my prescriber right away?
- Does the timing of my doses matter for this combination?
- Is there a safer alternative to one of these medications for me?
References (14)
- Product Information: Lopressor(R) oral tablets, metoprolol tartrate oral tablets. Validus Pharmaceuticals LLC (per FDA), Parsippany, NJ, 2023. DailyMed
- Brouwer RM, Follath F, & Buhler FR: Review of the cardiovascular adversity of the calcium antagonist beta-blocker combination: implications for antihypertensive therapy. J Cardiovasc Pharmacol 1985; 7(suppl 4):S38-S44. PubMed
- Bailey DG & Carruthers SG: Interaction between oral verapamil and beta-blockers during submaximal exercise: relevance of ancillary properties. Clin Pharmacol Ther 1991; 49:370-376.
- Keech AC, Harper RW, Harrison PM, et al: Extent and pharmacokinetic mechanisms of oral atenolol-verapamil interaction in man. Eur J Clin Pharmacol 1988; 35:363-366. PubMed
- Keech AC, Harper RW, Harrison PM, et al: Pharmacokinetic interactions between oral metoprolol and verapamil for angina pectoris. Am J Cardiol 1986; 58:551-552.
- Murdoch DL, Thomson GD, Thompson GG, et al: Evaluation of potential pharmacodynamic and pharmacokinetic interactions between verapamil and propranolol in normal subjects. Br J Clin Pharmacol 1991; 31:323-332. DOI
- Schwarz UI, Gramatte T, Krappweis J, et al: Unexpected effect of verapamil on oral bioavailability of the beta-blocker talinolol in humans. Clin Pharmacol Ther 1999; 65:283-290.
- Sakurai H, Kei M, & Matsubara K: Cardiogenic shock triggered by verapamil and atenolol - a case report of therapeutic experience with intravenous calcium. Jpn Circ J 2000; 64:893-896. PubMed
- Product Information: Betagon(R), mepindolol. Schering S.p.A. Milan, Italy, 2000.
- Product Information: Covera HS(R), verapamil. Pharmacia Corporation, Chicago, IL, 2003. DailyMed
- McCourty JC, Silas JH, Tucker GT, et al: The effect of combined therapy on the pharmacokinetics and pharmacodynamics of verapamil and propranolol in patients with angina pectoris. Br J Clin Pharmacol 1988; 25:349-357. PubMed
- Zatuchni J: Bradycardia and hypotension after propranolol HCl and verapamil. Heart Lung 1985; 14:94-95.
- Winniford MD, Fulton KL, & Hillis LD: Symptomatic sinus bradycardia during concomitant propranolol-verapamil administration. Am Heart J 1985; 110:498. DOI
- Pringle SD & MacEwen CJ: Severe bradycardia due to interaction of timolol eye drops and verapamil. Br Med J Clin Res Ed 1987; 294:155-156. PubMed
Keep reading about Verapamil
Keep reading about Atenolol
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