Should metoprolol (beta-blocker) be used in acute decompensated heart failure?

From the Guidelines

Metoprolol should not be initiated during acute decompensated heart failure (ADHF), but it can be considered in stable patients with heart failure with reduced ejection fraction (HFrEF) after optimization of volume status and discontinuation of intravenous diuretics, vasodilators, and inotropic agents, as recommended by the 2020 ACC/AHA clinical performance and quality measures for adults with heart failure 1. The use of beta-blockers, including metoprolol, in the acute setting of decompensated heart failure can worsen symptoms by reducing cardiac contractility and heart rate, potentially compromising cardiac output in unstable patients. Instead, the focus during ADHF should be on:

• Diuretics to reduce fluid overload
• Vasodilators to reduce afterload
• Possibly inotropes in severe cases to improve cardiac function If a patient is already on a chronic beta-blocker regimen, the decision to continue or temporarily reduce the dose should be individualized based on hemodynamic stability. Once the patient is stabilized, typically after resolution of volume overload and improved symptoms, beta-blockers can be initiated or resumed at low doses (such as metoprolol succinate 12.5-25 mg daily) and gradually titrated upward, as supported by the 2020 ACC/AHA guidelines 1. Beta-blockers are beneficial for long-term heart failure management as they reduce sympathetic stimulation, decrease heart rate, lower blood pressure, and promote reverse remodeling of the heart, ultimately improving survival and reducing hospitalizations in chronic heart failure patients, as noted in the 2020 ACC/AHA clinical performance and quality measures 1. The European Society of Cardiology also supports the use of beta-blockers in stable patients with heart failure, with caution in recently decompensated patients, and advises continuation of beta-blocker treatment during an episode of decompensation, with possible dose reduction, as stated in the 2012 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. In contrast, older guidelines, such as the 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults, also recommend the use of beta-blockers in patients with heart failure and reduced ejection fraction, but do not provide specific guidance on their use in acute decompensated heart failure 1. Overall, the most recent and highest-quality evidence supports the use of metoprolol and other beta-blockers in stable patients with heart failure with reduced ejection fraction, but advises against their initiation during acute decompensated heart failure, unless the patient is already on a chronic beta-blocker regimen and is hemodynamically stable.

From the FDA Drug Label

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 WARNINGS Heart Failure Beta-blockers, like metoprolol, can cause depression of myocardial contractility and may precipitate heart failure and cardiogenic shock.

Metoprolol should not be used in acute decompensated heart failure because it is contraindicated in patients with moderate-to-severe cardiac failure and can precipitate heart failure and cardiogenic shock 2 2.

From the Research

Metoprolol Usage in Acute Decompensated Heart Failure

• Metoprolol, a beta-blocker, can be used in patients with acute decompensated heart failure, particularly those with heart failure with reduced ejection fraction (HFrEF) 3, 4, 5, 6, 7.
• Studies have shown that beta-blocker therapy, including metoprolol, can reduce mortality and rehospitalization rates in patients with HFrEF 3, 4, 5, 6.
• The initiation of metoprolol in patients with acute decompensated heart failure should be done at a low dose, provided the patient is hemodynamically stable 3, 5.
• The dose of metoprolol should be gradually increased over weeks or months to achieve the maximum tolerated dose 4, 5, 6.
• Beta-blockers, including metoprolol, are not contraindicated in patients with decompensated heart failure, but the dose may need to be reduced or withheld temporarily in certain situations 5, 7.

Key Considerations

• Metoprolol should be initiated in patients with HFrEF who are already on beta-blocker therapy, and the therapy should be maintained during hospitalization for acute decompensated heart failure 3.
• The use of metoprolol in patients with severe acute heart failure, including those with resolved cardiogenic shock, requires careful consideration and monitoring 7.
• The benefits of metoprolol in patients with HFrEF include improved left ventricular function, reduced symptoms, and decreased mortality 4, 6.