What are the parameters to hold metoprolol (beta-blocker) tartrate?

Parameters for Holding Metoprolol Tartrate

Metoprolol tartrate should be held when patients present with signs of heart failure, evidence of a low output state, increased risk for cardiogenic shock, prolonged PR interval (>0.24 seconds), second or third-degree heart block, or active asthma/reactive airways disease. 1

Vital Sign Parameters

• Heart Rate: Hold if heart rate is consistently below 50 bpm 1

  • Some guidelines suggest holding if heart rate is <45-50 bpm 1
  • Risk factors for cardiogenic shock include heart rate <60 bpm 1

• Blood Pressure: Hold if systolic blood pressure is <100 mmHg 1

  • Risk factors for cardiogenic shock include systolic BP <120 mmHg 1

Clinical Conditions Requiring Metoprolol Tartrate to be Held

• Cardiac Conditions:

  • Signs of heart failure or decompensated heart failure 1
  • Evidence of a low output state 1
  • Increased risk for cardiogenic shock 1
  • Prolonged first-degree heart block (PR interval >0.24 seconds) 1
  • Second or third-degree heart block 1
  • Severe bradycardia 1
  • Hypotension 1

• Respiratory Conditions:

  • Active asthma 1
  • Reactive airways disease/bronchospastic airway disease 1

• Other Considerations:

  • When combined with non-dihydropyridine calcium channel blockers (e.g., diltiazem, verapamil) due to increased risk of bradycardia and heart block 1
  • Before non-cardiac surgery (if possible) to reduce risk of perioperative stroke 1

Risk Factors for Cardiogenic Shock

Patients with the following risk factors should be monitored closely, and metoprolol may need to be held if multiple factors are present:

• Age >70 years 1
• Systolic BP <120 mmHg 1
• Sinus tachycardia >110 bpm or heart rate <60 bpm 1
• Increased time since onset of symptoms of STEMI (if applicable) 1

Special Considerations

• Dosing: Metoprolol tartrate is typically dosed at 100-200 mg daily in divided doses (usually twice daily) 1

  • For IV administration, the dose is 5 mg every 5 minutes as tolerated up to 3 doses 1

• Perioperative Management:

  • Long-acting beta blockers may be superior to short-acting ones when therapy is initiated before surgery 1
  • Metoprolol should be tapered rather than abruptly discontinued to avoid rebound effects 1

• Overdose Management:

  • Severe overdose may require intravenous lipid emulsion and hyperinsulinemia/euglycemia therapy 2

Monitoring Parameters When Restarting

• Monitor heart rate, blood pressure, and symptoms of heart failure before each dose 1
• If previously held due to bradycardia, restart at a lower dose when heart rate is consistently >50 bpm 1
• If previously held due to hypotension, restart when systolic BP is consistently >100 mmHg 1

Remember that abrupt cessation of metoprolol tartrate should be avoided when possible, as this can lead to rebound effects and worsening of underlying conditions 1.