From the Guidelines
Metoprolol succinate should be held or dose-reduced in patients with hypotension and tachycardia, especially if diastolic pressure is low and heart rate exceeds 70, to prevent worsening of hypotension and potential adverse effects on morbidity, mortality, and quality of life. When managing metoprolol succinate in such patients, it is crucial to consider the potential risks and benefits, as beta-blockers can reduce heart rate and contractility, which may worsen hypotension in volume-depleted states 1.
Key Considerations
- For patients with symptomatic hypotension (systolic BP <90 mmHg) and tachycardia, the metoprolol dose should be reduced by 50% or held completely until blood pressure stabilizes.
- When restarting, begin at a lower dose (such as 25 mg daily) and titrate slowly while monitoring vital signs.
- The underlying cause of both the hypotension and tachycardia should be investigated, as tachycardia may be a compensatory mechanism for low blood pressure.
- Fluid status should be optimized before adjusting beta-blocker therapy, as volume depletion can exacerbate hypotension.
Alternative Therapies
- In cases where both blood pressure control and heart rate management are needed, consider alternative agents like diltiazem or combination therapy with medications that have less hypotensive effect 1.
- Regular monitoring of blood pressure, heart rate, and symptoms is essential during any adjustment period.
Guideline Recommendations
- The use of beta-blockers, such as metoprolol succinate, is recommended for patients with heart failure and reduced ejection fraction, unless contraindicated, to reduce morbidity and mortality 1.
- However, in patients with hypotension and tachycardia, careful consideration and dose adjustment are necessary to balance the benefits and risks of beta-blocker therapy.
From the FDA Drug Label
CLINICAL PHARMACOLOGY Mechanism of Action Metoprolol is a beta 1-selective (cardioselective) adrenergic receptor blocker. Pharmacodynamics Relative beta 1 selectivity is demonstrated by the following: In several studies of patients with acute myocardial infarction, intravenous followed by oral administration of metoprolol caused a reduction in heart rate, systolic blood pressure and cardiac output Stroke volume, diastolic blood pressure and pulmonary artery end diastolic pressure remained unchanged. OVERDOSAGE Acute Toxicity Several cases of overdosage have been reported, some leading to death. Signs and Symptoms Potential signs and symptoms associated with overdosage with metoprolol are bradycardia, hypotension, bronchospasm, myocardial infarction, cardiac failure and death. Management There is no specific antidote Hypotension Administer a vasopressor, e.g., norepinephrine or dopamine.
Management of Metoprolol Succinate in Hypotension and Tachycardia:
- Hypotension: Metoprolol can cause a reduction in systolic blood pressure and cardiac output, which may worsen hypotension.
- Tachycardia: Metoprolol can reduce heart rate, which may be beneficial in tachycardia.
- Key Consideration: In patients with hypotension (diastolic pressure is low) and tachycardia (heart rate exceeding 70), metoprolol succinate should be used with caution.
- Recommendation:
- Monitor blood pressure and heart rate closely.
- Consider withholding or reducing the dose of metoprolol succinate if hypotension worsens or if the patient becomes symptomatic.
- Administer a vasopressor (e.g., norepinephrine or dopamine) if hypotension occurs, as per the management of overdose 2.
- Consult with a healthcare professional for personalized guidance, as the FDA drug label does not provide explicit instructions for managing metoprolol succinate in this specific scenario 2 2.
From the Research
Management of Metoprolol Succinate in Patients with Hypotension and Tachycardia
- Metoprolol succinate is a beta blocker used to manage hypertension, angina, and heart failure 3, 4.
- In patients with hypotension (low blood pressure) and tachycardia (heart rate exceeding 70), the management of metoprolol succinate requires careful consideration of the potential effects on blood pressure and heart rate.
Effects of Metoprolol Succinate on Blood Pressure
- Studies have shown that metoprolol succinate can decrease both systolic and diastolic blood pressure in patients with hypertension 3.
- However, in patients with hypotension, further decreases in blood pressure may be undesirable and potentially harmful.
- A study found that a diastolic blood pressure of less than 60 mmHg was associated with increased risk of cardiovascular events in patients with high cardiovascular risk and a treated systolic blood pressure less than 130 mmHg 5.
- Another study found that a diastolic blood pressure of 70 to <80 mmHg was associated with the lowest risk of cardiovascular outcomes in patients with high cardiovascular risk and a mean achieved systolic blood pressure of 120 to <140 mmHg 6.
Effects of Metoprolol Succinate on Heart Rate
- Metoprolol succinate can also decrease heart rate in patients with tachycardia 4, 7.
- However, in patients with hypotension, decreases in heart rate may be undesirable and potentially harmful.
- A study found that metoprolol succinate was effective in achieving rate control in patients with supraventricular tachycardia, but was associated with a higher risk of hypotension compared to diltiazem 7.
Considerations for Managing Metoprolol Succinate in Patients with Hypotension and Tachycardia
- In patients with hypotension and tachycardia, the dose of metoprolol succinate may need to be adjusted to balance the potential benefits of blood pressure and heart rate control with the potential risks of hypotension and bradycardia.
- Close monitoring of blood pressure and heart rate is necessary to ensure that the patient is not experiencing adverse effects from the medication.
- Alternative medications, such as diltiazem, may be considered in patients who are at high risk of hypotension or bradycardia 7.