Is metoprolol (beta blocker) contraindicated in acute decompensated heart failure?

From the Guidelines

No, metoprolol is not contraindicated in acute decompensated heart failure, and it can be considered in certain cases, such as when ongoing ischemia and tachycardia are present, with cautious use. In patients with acute decompensated heart failure, metoprolol, a beta-blocker, may be used cautiously, especially in those with ongoing ischemia and tachycardia, as stated in the European Society of Cardiology guidelines 1. The guidelines suggest that in patients with overt acute heart failure and more than basal pulmonary rales, beta-blockers should be used cautiously, and intravenous metoprolol can be considered in certain cases, with a Class IIb recommendation, level of evidence C 1. However, in patients with an acute myocardial infarction who stabilize after developing acute heart failure, beta-blockers should be initiated early, with a Class IIa recommendation, level of evidence B 1. Additionally, the 2008 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure recommend that in patients with acutely decompensated heart failure, the dose of beta-blocker may need to be reduced temporarily or omitted, although generally treatment should not be stopped, unless the patient is clinically unstable, with a Class of recommendation I, level of evidence A 1. Key points to consider when using metoprolol in acute decompensated heart failure include:

• Starting with a low dose, such as 12.5 mg twice daily of metoprolol succinate, and gradually increasing as tolerated
• Close monitoring of vital signs, symptoms, and fluid status
• Educating patients about potential side effects, such as dizziness, fatigue, or worsening shortness of breath, and instructing them to report these symptoms promptly
• Temporarily reducing or discontinuing metoprolol in cases of severe decompensation or cardiogenic shock, and restarting and titrating up slowly once the patient stabilizes.

From the FDA Drug Label

CONTRAINDICATIONS Hypersensitivity to metoprolol and related derivatives, or to any of the excipients; hypersensitivity to other beta-blockers (cross sensitivity between beta-blockers can occur). Myocardial Infarction Metoprolol is contraindicated in patients with a heart rate < 45 beats/min; second- and third-degree heart block; significant first-degree heart block (P-R interval ≥ 0.24 sec); systolic blood pressure < 100 mmHg; or moderate-to-severe cardiac failure (see WARNINGS). WARNINGS Heart Failure Beta-blockers, like metoprolol, can cause depression of myocardial contractility and may precipitate heart failure and cardiogenic shock. If signs or symptoms of heart failure develop, treat the patient according to recommended guidelines. It may be necessary to lower the dose of metoprolol or to discontinue it

Metoprolol is contraindicated in moderate-to-severe cardiac failure. However, the question asks about acute decompensated heart failure. The label does not explicitly address this condition as a contraindication.

• The label warns that beta-blockers, like metoprolol, can precipitate heart failure and cardiogenic shock.
• It advises to treat the patient according to recommended guidelines if signs or symptoms of heart failure develop. Based on the information provided, metoprolol is not explicitly contraindicated in acute decompensated heart failure, but caution is advised due to the potential to precipitate heart failure and cardiogenic shock 2 2.

From the Research

Metoprolol in Acute Decompensated Heart Failure

• Metoprolol, a beta-blocker, is not contraindicated in acute decompensated heart failure, although the dose may need to be reduced or withheld temporarily 3.
• The use of beta-blockers, including metoprolol, in heart failure is recommended for all stable subjects with current or previous symptoms of heart failure and heart failure with reduced ejection fraction, unless there is a contraindication 4.
• In patients with decompensated heart failure, beta-blockers can be used, but the dose may need to be adjusted 3.

Key Considerations

• Beta-blockers, including metoprolol, should be initiated at a low dose and gradually increased as tolerated to achieve the desired clinical effects on heart rate and symptom control 4, 3.
• The target dose of metoprolol should be the maximum tolerated for adequate bradycardia, with the goal of reducing mortality and hospitalization in patients with heart failure 5, 3.
• In clinical practice, the doses of beta-blockers used are often substantially less than the recommended target doses, and further efforts are needed to overcome this beta-blocker titration gap 6.

Specific Studies

• The MERIT-HF trial demonstrated a 34% reduction in relative risk of all-cause mortality in patients with chronic heart failure treated with metoprolol CR/XL 5.
• The OPTIMIZE-HF registry found that only 17.5% and 7.9% of patients were being treated with recommended target doses of carvedilol and metoprolol succinate, respectively, at 60- to 90-day postdischarge follow-up 6.
• A study published in The American Journal of Medicine found that high-dose beta-blocker use, including metoprolol, was associated with a significantly lower risk of death in patients with heart failure with preserved ejection fraction and elevated heart rate 7.