What parameters indicate holding metoprolol?

From the Guidelines

Metoprolol should be held in patients with certain parameters, including hypotension (systolic blood pressure less than 90 mm Hg), significant sinus bradycardia (heart rate less than 50 beats per minute), marked first-degree AV block (ECG PR interval greater than 0.24 s), any form of second- or third-degree AV block in the absence of a functioning implanted pacemaker, a history of asthma, severe LV dysfunction or HF (e.g., rales or S3 gallop), or at high risk for shock 1.

Key Parameters to Consider

• Hypotension: Metoprolol can worsen hypotension, so it should be held in patients with systolic blood pressure less than 90 mm Hg.
• Bradycardia: Metoprolol can cause bradycardia, so it should be held in patients with significant sinus bradycardia (heart rate less than 50 beats per minute).
• AV Block: Metoprolol can worsen AV block, so it should be held in patients with marked first-degree AV block (ECG PR interval greater than 0.24 s) or any form of second- or third-degree AV block in the absence of a functioning implanted pacemaker.
• Asthma: Metoprolol can worsen asthma, so it should be held in patients with a history of asthma.
• Severe LV Dysfunction or HF: Metoprolol can worsen HF, so it should be held in patients with severe LV dysfunction or HF (e.g., rales or S3 gallop).
• High Risk for Shock: Metoprolol can increase the risk of cardiogenic shock, so it should be held in patients at high risk for shock.

Additional Considerations

• Patients with significant chronic obstructive pulmonary disease who may have a component of reactive airway disease should be given metoprolol very cautiously, with initial low doses of a beta-1–selective agent 1.
• Patients with mild wheezing or a history of chronic obstructive pulmonary disease should receive a short-acting cardioselective agent at a reduced dose (e.g., 12.5 mg of metoprolol orally) rather than the complete avoidance of a beta blocker 1.
• The COMMIT trial found that patients at highest risk for cardiogenic shock due to intravenous beta blockade were those with tachycardia or in Killip Class II or III 1.

From the FDA Drug Label

If signs or symptoms of heart failure develop, treat the patient according to recommended guidelines. It may be necessary to lower the dose of metoprolol or to discontinue it If angina markedly worsens or acute coronary insufficiency develops, metoprolol administration should be reinstated promptly, at least temporarily, and other measures appropriate for the management of unstable angina should be taken. If severe bradycardia develops, reduce or stop metoprolol

The parameters that indicate holding metoprolol are:

• Development of signs or symptoms of heart failure
• Marked worsening of angina or development of acute coronary insufficiency
• Development of severe bradycardia 2

From the Research

Parameters Indicating Holding Metoprolol

The decision to hold metoprolol is typically based on various clinical parameters and patient-specific factors. Some of these parameters include:

• Blood pressure: Metoprolol is used to treat hypertension, and holding the medication may be considered if blood pressure becomes too low 3.
• Heart rate: Metoprolol can cause bradycardia (slow heart rate), and holding the medication may be necessary if heart rate becomes too slow 3, 4.
• Cardiac index: Changes in cardiac index may indicate the need to hold metoprolol, particularly in patients with essential hypertension 4.
• Total peripheral resistance: Increases in total peripheral resistance may be a concern in patients taking metoprolol, and holding the medication may be considered in such cases 4.
• Capillary blood flow: Decreases in capillary blood flow may indicate the need to hold metoprolol, particularly in patients with essential hypertension 4.
• Plasma renin activity: Metoprolol can decrease plasma renin activity, and holding the medication may be considered if plasma renin activity becomes too low 3.
• Pharmacokinetic parameters: Parameters such as maximum plasma concentration (Cmax), time to reach maximum plasma concentration (Tmax), and area under the concentration-time curve (AUC) may be monitored to determine the need to hold metoprolol 5.

Disease-Specific Considerations

In certain diseases, holding metoprolol may be necessary due to changes in pharmacokinetic parameters or disease-specific considerations. For example:

• Renal impairment: Patients with renal impairment may require dose adjustments or holding of metoprolol due to changes in clearance (CL) 5.
• Hepatic cirrhosis: Patients with hepatic cirrhosis may require dose adjustments or holding of metoprolol due to changes in CL 5.
• Acute myocardial infarction: Patients with acute myocardial infarction may require dose adjustments or holding of metoprolol due to changes in Cmax and AUC 5.