Metoprolol Dosing for Palpitations
The typical dose of metoprolol for treating palpitations is 25-100 mg twice daily of the tartrate formulation, with an initial recommended dose of 25 mg twice daily that can be titrated upward based on heart rate response. 1
Dosing Guidelines
Initial Dosing
- Metoprolol tartrate: Start with 25 mg twice daily 1
- Acute setting: For rapid control, IV metoprolol can be given as 2.5-5 mg IV bolus over 1-2 minutes, repeated up to 3 doses if needed 2
Maintenance and Titration
- Increase dose gradually at 2-4 week intervals based on heart rate response 1
- Titration steps: 25 mg BID → 50 mg BID → 100 mg BID (maximum recommended dose) 1
- Target heart rate: Typically <100 bpm for symptom control 1
Alternative Formulations
- Metoprolol succinate (extended-release): 50-400 mg once daily 1
- When switching from tartrate to succinate, use the same total daily dose (e.g., 50 mg BID tartrate = 100 mg daily succinate) 1
Clinical Considerations
Mechanism for Palpitation Control
- Metoprolol is a β1-selective blocker that reduces:
- Heart rate
- Cardiac output
- AV node conduction
- Effects of circulating catecholamines 2
Contraindications
- Severe bradycardia
- High-grade AV block (without pacemaker)
- Cardiogenic shock
- Decompensated heart failure
- Asthma or obstructive airway disease
- Pre-excited atrial fibrillation or flutter 2, 1
Monitoring
- Heart rate
- Blood pressure
- Symptoms of heart failure
- Symptoms of bronchospasm 1
Potential Side Effects
Important Cautions
- Never abruptly discontinue metoprolol as this can cause rebound tachycardia 1
- For patients with heart failure, start with lower doses and titrate more gradually 2, 1
- A 10:1 ratio is used when converting from IV to oral metoprolol (5 mg IV ≈ 50 mg oral) 1
Alternative Beta-Blockers
If metoprolol is not tolerated, consider:
- Atenolol: 25-100 mg daily
- Bisoprolol: 2.5-10 mg daily
- Carvedilol: 3.125-25 mg BID (preferred if heart failure is present) 1
For most patients with palpitations, metoprolol tartrate at 25-100 mg twice daily provides effective symptom control with a favorable safety profile when appropriately dosed and monitored.