From the Guidelines
Transitioning from metoprolol to an ACE inhibitor should be done gradually under medical supervision, starting by reducing metoprolol dose by 25-50% every 1-2 weeks while monitoring blood pressure and heart rate, and then initiating a low dose of an ACE inhibitor such as lisinopril 2.5-5mg daily or enalapril 2.5mg daily, with gradual dose increases every 1-2 weeks as metoprolol is further reduced, as recommended by the most recent guidelines 1.
Key Considerations
- The transition process should prioritize monitoring for side effects, including dizziness, cough, or changes in kidney function, to prevent rebound hypertension or worsening of underlying heart conditions that can occur with abrupt beta-blocker discontinuation.
- The choice of ACE inhibitor and its initial dose should be based on the patient's specific condition and the guidelines provided by recent studies, such as those outlined in the European Society of Cardiology guidelines 1.
- It is crucial to check renal function and electrolytes before starting the ACE inhibitor and to re-check blood chemistry 1–2 weeks after initiation and 1–2 weeks after final dose titration, as advised in the guidelines 1.
Monitoring and Dose Adjustment
- Blood pressure, renal function, and electrolytes should be monitored closely during the transition period, with adjustments made as necessary to prevent adverse effects.
- The dose of the ACE inhibitor should be doubled at not less than 2-week intervals in the community, or more rapidly in a hospital setting with close monitoring, tolerability permitting, as recommended by the guidelines 1.
- The goal is to aim for the target dose or the highest tolerated dose, remembering that some ACE inhibitor is better than none, as emphasized in the guidelines 1.
Patient Education and Follow-Up
- A specialist HF nurse may assist with patient education, follow-up, biochemical monitoring, and dose up-titration to ensure a smooth transition and optimal patient outcomes.
- Patients should be instructed to contact their doctor immediately if they experience chest pain, severe dizziness, significant blood pressure changes, or worsening symptoms during the transition, highlighting the importance of close medical supervision throughout this process.