Should I stop taking metoprolol (beta-blocker) in congestive heart failure (CHF)?

Should You Stop Metoprolol in Congestive Heart Failure?

No, you should not stop metoprolol in congestive heart failure—beta-blockers like metoprolol are first-line therapy that reduce mortality by 34-39% and should be continued except in rare circumstances of severe deterioration. 1, 2

Core Principle: Beta-Blockers Save Lives in Heart Failure

• Metoprolol CR/XL (controlled-release/extended-release formulation) reduces all-cause mortality, sudden death, and death from progressive heart failure in patients with chronic heart failure 2
• The MERIT-HF trial demonstrated a 34% reduction in relative risk of death, with particular benefit in reducing sudden death (41% reduction) and heart failure progression deaths (49% reduction) 2
• Beta-blockers should never be stopped suddenly unless absolutely necessary due to risk of rebound myocardial ischemia, infarction, and arrhythmias 1, 3

When to Adjust (Not Stop) Metoprolol

For Worsening Congestion (dyspnea, edema, weight gain):

• First step: Increase diuretic dose 1
• Second step: If diuretics don't work, halve the metoprolol dose (rarely necessary) 1
• Review patient in 1-2 weeks; seek specialist advice if no improvement 1

For Marked Fatigue:

• Halve the metoprolol dose (rarely necessary) 1
• Review in 1-2 weeks 1

For Symptomatic Bradycardia (heart rate <50 bpm with symptoms):

• Halve the metoprolol dose 1
• Review other heart rate-slowing medications (digoxin, amiodarone, diltiazem, verapamil) 1
• Obtain ECG to exclude heart block 1
• Seek specialist advice 1

When Complete Discontinuation May Be Considered (Extremely Rare)

Only stop metoprolol in cases of serious deterioration where dose reduction fails, and ideally only after specialist consultation 1:

• Severe clinical deterioration despite halving the dose 1
• Severe symptomatic bradycardia with heart rate <50 bpm that doesn't respond to dose reduction 1
• Development of heart block 1

Critical Cautions

The "Rebound" Risk:

• Abrupt discontinuation can cause severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias 3
• If discontinuation is absolutely necessary, taper gradually over 1-2 weeks 3
• The FDA label specifically warns against abrupt discontinuation in patients with coronary artery disease 3

Important Context:

• Asymptomatic low blood pressure does not require any change in therapy 1
• Temporary symptomatic deterioration occurs in 20-30% of patients during initiation but usually resolves with medication adjustment 1
• Some beta-blocker is better than no beta-blocker—even lower doses provide benefit 1

Formulation Matters

• Only metoprolol CR/XL (controlled-release/extended-release) has proven mortality benefit in heart failure 1, 2
• Metoprolol tartrate (immediate-release) should not be used in preference to metoprolol CR/XL for heart failure 1
• Target dose is 200 mg once daily, starting from 12.5-25 mg and titrating up every 2 weeks 1

Evidence Quality

The European Society of Cardiology guidelines (2012) 1 provide the most comprehensive and recent guidance, supported by the landmark MERIT-HF trial 2 which enrolled 3,991 patients and was stopped early due to clear mortality benefit. Even in severe heart failure (NYHA class III/IV with ejection fraction <0.25), metoprolol CR/XL reduced mortality by 39% 4.