What is the most appropriate metoprolol formulation, metoprolol succinate or metoprolol tartrate, for a patient with Coronary Artery Disease (CAD) without angina, Pulmonary Hypertension (PH), and Hyperlipidemia?

From the Guidelines

For a patient with CAD without angina, pulmonary hypertension, and hyperlipidemia, metoprolol succinate would be the most appropriate choice. This recommendation is based on the 2023 chronic coronary disease guideline-at-a-glance from the Journal of the American College of Cardiology 1. Metoprolol succinate is an extended-release formulation that provides consistent 24-hour beta-blockade with once-daily dosing, which improves adherence and provides more stable blood pressure and heart rate control. The guideline recommends the use of sustained release metoprolol succinate, carvedilol, or bisoprolol with titration to target doses in patients with CCD and LVEF <50% 1. Although the patient's LVEF is not specified, metoprolol succinate is still a preferred option due to its extended-release properties, which provide more gradual effects on hemodynamics. This is advantageous in pulmonary hypertension where abrupt changes in cardiac output should be avoided. Some key points to consider when prescribing metoprolol succinate include:

• The typical starting dose is 25-50 mg once daily, which can be titrated up to 200 mg daily based on clinical response.
• Metoprolol tartrate, while effective, requires twice-daily dosing due to its shorter half-life, which may lead to fluctuating drug levels and potentially less consistent symptom control.
• Both formulations would have similar effects on the patient's hyperlipidemia profile, as beta-blockers generally have minimal impact on lipid metabolism.
• The use of beta-blocker therapy is recommended to reduce the risk of future MACE, including cardiovascular death, in patients with CCD and LVEF #40% with or without previous MI 1.

From the Research

Metoprolol Options for CAD without Angina, Pulmonary Hypertension, and Hyperlipidemia

• The patient's condition involves coronary artery disease (CAD) without angina, pulmonary hypertension, and hyperlipidemia, requiring careful consideration of the most appropriate metoprolol formulation.
• Metoprolol succinate and metoprolol tartrate are two available formulations, with metoprolol succinate being a controlled-release formulation and metoprolol tartrate being a conventional, immediate-release formulation.

Comparison of Metoprolol Formulations

• A study published in 2003 2 compared the safety of metoprolol CR (controlled release) and conventional metoprolol in patients with CAD and chronic obstructive pulmonary disease (COPD), finding no significant decrease in forced expiratory volume in 1 s (FEV(1)) in either group.
• The study suggests that metoprolol, a beta-1 selective blocker, can be used safely in CAD patients with COPD, but does not directly address the patient's specific condition of pulmonary hypertension and hyperlipidemia.

Treatment Guidelines for CAD and Hypertension

• Guidelines for treating hypertension in patients with CAD recommend using beta blockers and ACE inhibitors or angiotensin receptor blockers (ARBs) 3, 4.
• The guidelines also suggest that long-acting nitrates are effective antianginal and anti-ischemic drugs, and calcium-channel blockers (CCBs) may be added if angina persists despite beta blockers and long-acting nitrates.

Metoprolol in Cardiovascular Disease

• A review of metoprolol in the treatment of cardiovascular disease published in 2018 5 discusses the use of metoprolol, with a focus on the extended-release formulation, in clinical practice, highlighting its suitability in different cardiovascular conditions.
• However, the review does not provide specific guidance on the choice between metoprolol succinate and metoprolol tartrate for a patient with CAD without angina, pulmonary hypertension, and hyperlipidemia.

Considerations for Metoprolol Choice

• Given the patient's condition, metoprolol succinate (extended-release formulation) may be preferred due to its controlled-release properties, which can provide a more consistent and stable therapeutic effect.
• However, the choice between metoprolol succinate and metoprolol tartrate should be based on individual patient factors and clinical judgment, taking into account the patient's specific condition and medical history.