Why should metoprolol (metoprolol tartrate) not be held and how do I write an order to notify the managing physician (MD) for holding it?

Metoprolol Tartrate: When Not to Hold and How to Write Holding Orders

Metoprolol tartrate should not be abruptly discontinued in patients with coronary artery disease due to risk of severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias. 1

Why Metoprolol Should Not Be Routinely Held

• Abrupt discontinuation of metoprolol in patients with coronary artery disease can lead to severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias 1
• Long-term use of oral beta-blockers is strongly recommended (Class I, Level of Evidence: A) for secondary prevention in high-risk patients, such as those with low ejection fraction or heart failure 2
• Beta-blockers like metoprolol reduce the risk of reinfarction and ventricular fibrillation when continued beyond the initial acute phase 2
• For patients with atrial fibrillation, metoprolol is an important medication for rate control and should be maintained unless specific contraindications exist 2

Situations When Holding Metoprolol Is Appropriate

• Signs of heart failure or cardiogenic shock 2, 1
• Evidence of a low output state 2
• Severe bradycardia (heart rate <60 bpm) 2, 1
• Hypotension (systolic blood pressure <120 mmHg) 2
• PR interval greater than 0.24 seconds 2
• Second or third-degree heart block 2, 1
• Active asthma or reactive airway disease 2, 1

How to Write a Proper Holding Order

1. Specific parameters for holding:

   • "Hold metoprolol tartrate if:
     • Heart rate <50 bpm
     • Systolic blood pressure <90 mmHg
     • Signs of acute heart failure or cardiogenic shock
     • New onset second or third-degree heart block" 2, 3, 1

2. Notification parameters:

   • "Notify MD if metoprolol is held for any reason, or if:
     • Heart rate <50 bpm or >110 bpm
     • Systolic blood pressure <90 mmHg
     • Patient develops shortness of breath, increased fatigue, or signs of heart failure
     • New conduction abnormalities on ECG" 2, 3

3. Resumption guidance:

   • "If medication is held, do not restart without MD reassessment. Document reason for holding in chart." 2, 3

Special Considerations

• For patients who have recently experienced decompensated heart failure, metoprolol can be safely continued during episodes of decompensation, though dose reduction may be necessary 2
• If metoprolol must be discontinued in patients with coronary artery disease, it should be tapered gradually over 1-2 weeks to prevent rebound effects 3, 1
• Temporary discontinuation is advised in shocked or severely hypoperfused patients, but re-institution should be attempted before discharge 2
• In patients with ST-elevation myocardial infarction, the risk of cardiogenic shock with metoprolol is highest during days 0-1 after admission, while benefits in reducing reinfarction and ventricular fibrillation emerge more gradually 4

Common Pitfalls to Avoid

• Avoid writing vague holding parameters (e.g., "hold if unstable") - instead, specify exact vital sign thresholds 3
• Do not write orders that fail to include notification parameters for the physician 3
• Remember that even if metoprolol is held temporarily, it should generally not be discontinued abruptly in patients with coronary artery disease 1
• Avoid holding metoprolol unnecessarily in stable patients, as the medication provides important long-term benefits for cardiovascular outcomes 2, 5