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Short version: Less ammo, and everything does far more damage to both you and the enemies.
I'd actually recommend hardcore. Its an interesting (if sometimes frustrating) experience to have a whole world of glass-canons you have to treverse.
Rather than the FPS standard of your hands magically turning bullets to nerf at higher difficulty levels you really feel like combat is dangerus and preferably avoidable in Metro.
I'll take out a group of 6 guys and find like 2 bullets in their AK.
To be fair, it is the post apocalypse. Scarcerity is part of that.
But yeah, the enemies having infinity + 1 magazines until you kill them is an annoying old trope. It would have been neat if they only had so much ammo, original Deus Ex style.
Survival (for redux) Ranger Hardcore is the most realistic way to play. You can still find more than enough ammo.