What type of metoprolol (beta-blocker) is recommended for heart failure with preserved ejection fraction (HFpEF)?

Metoprolol Succinate is the Recommended Beta-Blocker for Heart Failure with Preserved Ejection Fraction

For patients with heart failure with preserved ejection fraction (HFpEF), metoprolol succinate (extended-release) is the recommended formulation of metoprolol due to its once-daily dosing, consistent 24-hour beta-blockade, and established safety profile in heart failure patients. 1

Evidence-Based Rationale

Metoprolol Formulation Selection

• Metoprolol succinate (extended-release) is specifically designed to deliver medication at a near-constant rate for approximately 20 hours, providing even plasma concentrations over a 24-hour period 2
• Unlike immediate-release metoprolol tartrate, the extended-release formulation avoids marked peaks and troughs in plasma concentration, resulting in consistent beta1-blockade over 24 hours while maintaining cardioselectivity at doses up to 200 mg daily 2
• The 2013 ACCF/AHA guidelines specifically identify sustained-release metoprolol succinate (not metoprolol tartrate) as one of the three beta-blockers proven to reduce mortality in heart failure patients 3

Beta-Blockers in HFpEF

• While the strongest evidence for beta-blockers exists for heart failure with reduced ejection fraction (HFrEF), metoprolol succinate has shown potential benefit in HFpEF patients as demonstrated in pilot studies 4
• In a randomized, double-blind, placebo-controlled pilot trial, metoprolol succinate showed improvement in quality of life parameters and functional capacity in HFpEF patients 4

Dosing and Titration Protocol

Initial Dosing

• Start at a low dose: 12.5-25 mg once daily 1
• For patients transitioning from carvedilol:
  • Low-dose carvedilol (3.125-6.25 mg twice daily) → Start metoprolol succinate at 25 mg once daily
  • Medium-dose carvedilol (12.5 mg twice daily) → Start metoprolol succinate at 50 mg once daily
  • High-dose carvedilol (25 mg twice daily) → Start metoprolol succinate at 100 mg once daily 1

Titration Schedule

• Increase dose gradually at 2-week intervals 1
• Target dose: 200 mg once daily 1
• Follow the "start low, go slow" approach, which is essential in heart failure patients 1

Monitoring and Management

Parameters to Monitor

• Heart rate and blood pressure at each dose titration
• Signs of fluid retention
• Symptoms of heart failure
• Renal function and electrolytes

Managing Adverse Effects

• For worsening heart failure: Increase diuretic or ACE inhibitor dose, or temporarily reduce beta-blocker dose
• For hypotension: Reduce vasodilator doses first, then adjust beta-blocker if necessary
• For bradycardia: Reduce or discontinue other medications that decrease heart rate before adjusting beta-blocker 1

Important Considerations

Contraindications

• Asthma or severe bronchial disease
• Symptomatic bradycardia or hypotension 1

Cautions

• Never stop beta-blockers suddenly due to risk of rebound effects, including increased myocardial ischemia/infarction and arrhythmias 1
• Patients with diabetes, impaired renal function, or low serum sodium require close monitoring 3

Combination Therapy for HFpEF

• Beta-blockers like metoprolol succinate can be used in combination with:
  • ACE inhibitors or ARBs
  • Diuretics for symptom management
  • SGLT2 inhibitors, which have shown benefit in heart failure regardless of ejection fraction 3, 1

By following these evidence-based recommendations for metoprolol succinate in HFpEF, clinicians can optimize treatment while minimizing adverse effects and potentially improving quality of life for patients with this challenging condition.