Metoprolol Therapy Guidelines

Absolute Contraindications

The American College of Cardiology and European Heart Journal recommend that metoprolol should be held in patients with active asthma or reactive airways disease 2, 3
The European Heart Journal states that metoprolol is contraindicated in patients with cardiogenic shock or increased risk for cardiogenic shock 3

The American College of Cardiology recommends caution in patients with a low-output state, such as oliguria, when using metoprolol 1
The American College of Cardiology suggests that metoprolol should be used with caution in patients with significant sinus bradycardia (heart rate <50 beats/min) 1
The American College of Cardiology recommends that metoprolol be used with caution in patients with hypotension (systolic blood pressure <90 mm Hg) 1
The American College of Cardiology states that metoprolol should be used with caution in patients with chronic obstructive pulmonary disease with a reactive airway component 1

The European Heart Journal recommends that in patients admitted for worsening heart failure, metoprolol dose may need to be reduced 2
The European Heart Journal suggests that in severe situations, temporary discontinuation of metoprolol can be considered 2
The European Heart Journal recommends that low-dose therapy should be reinstituted and up-titrated once the patient's clinical condition improves, preferably before discharge 2
The American College of Cardiology recommends that for patients undergoing non-cardiac surgery, metoprolol should be held if heart rate is consistently below 45 bpm or systolic blood pressure drops below 100 mmHg 4
The American College of Cardiology suggests that if heart rate is 45-49 bpm with systolic blood pressure >100 mmHg, the next dose of metoprolol should be delayed for 12 hours 4
The American College of Cardiology states that patients with tachycardia or in Killip Class II or III are at highest risk for cardiogenic shock with IV beta blockade 4

The American College of Cardiology recommends that blood pressure and heart rate should be checked before each administration of metoprolol 4, 3
The American College of Cardiology states that the target resting heart rate is 50-60 beats per minute unless limiting side effects occur 1, 3
The American College of Cardiology recommends monitoring for signs of worsening heart failure, such as rales or S3 gallop, during metoprolol therapy 1
The American College of Cardiology suggests continuous ECG monitoring during intravenous administration of metoprolol 1
The American College of Cardiology recommends auscultation for rales and bronchospasm during metoprolol therapy 1

The American College of Cardiology recommends that when resuming metoprolol therapy after holding for hypotension or bradycardia, the dose should be started at a lower level and titrated gradually 4
The European Heart Journal suggests that for patients with heart failure, low-dose therapy should be reinstituted and up-titrated as soon as the clinical condition permits 2
The American College of Cardiology and Praxis Medical Insights recommend avoiding abrupt cessation of metoprolol therapy to prevent rebound hypertension or worsening of angina 5, 3

The American College of Cardiology and Praxis Medical Insights recommend never abruptly discontinuing metoprolol as it may induce rebound hypertension or worsening angina 5, 3
The American College of Cardiology states that for patients with heart failure, beta-blockers are strongly recommended before discharge even if temporarily held during acute decompensation 1
The American College of Cardiology recommends that patients at highest risk for adverse events are those with tachycardia or in Killip Class II or III 4