Objective: To treat unstable angina pectoris in elderly patients with coronary heart disease with metoprolol and evaluate its therapeutic effect. Methods: A total of 76 elderly patients with unstable angina pectoris due to coronary heart disease who visited our hospital from June 2024 to June 2025 were selected and randomly divided into the observation group and the control group by the random number table method. The control group was treated with aspirin + isosorbide nitrate, while the observation group was treated with metoprolol based on the above combination. The therapeutic effects of the two groups were compared. Result: The positive improvement amplitude of blood lipid levels and cardiac function indicators in the observation group after treatment was greater than that in the control group. Moreover, the SAQ score of the observation group was higher than that of the control group, the GRACE score was lower than that of the control group, and the effective rate of treatment was higher than that of the control group (P < 0.05). There was no difference in the rate of adverse drug reactions between groups (P > 0.05). Conclusion: Metoprolol in the treatment of unstable angina pectoris in elderly patients with coronary heart disease has an ideal and positive regulatory effect on blood lipids and cardiac function of patients. At the same time, it can reduce the occurrence of angina pectoris. The overall therapeutic effect is remarkable and the safety is ideal. It is worthy of promotion.