Does Metoprolol Lower Blood Pressure?
Yes, metoprolol effectively lowers blood pressure through competitive antagonism of catecholamines at cardiac adrenergic receptors, leading to decreased cardiac output and reduced sympathetic outflow. 1
Mechanism of Blood Pressure Reduction
Metoprolol is a beta-1 selective (cardioselective) adrenergic receptor blocker that lowers blood pressure through several mechanisms 1:
- Decreased cardiac output by blocking catecholamine-induced increases in heart rate and myocardial contractility 1
- Reduced sympathetic outflow to the peripheral vasculature through central nervous system effects 1
- Suppression of renin activity in the kidneys 1
The clinical pharmacology demonstrates blood pressure lowering through reduction in systolic blood pressure upon exercise and decreased cardiac output at rest and during activity 1.
Clinical Efficacy Data
Metoprolol produces significant reductions in both systolic and diastolic blood pressure, with 60-85% of patients achieving diastolic blood pressure ≤90 mmHg within 12 weeks of treatment 2. The maximum antihypertensive effect occurs after approximately three weeks of therapy 2.
In comparative studies, metoprolol achieved mean reductions in supine blood pressure of 26/15 mmHg after 36 weeks of treatment 3. The drug demonstrates efficacy similar to other beta-blockers when given in equiactive beta-blocking dosages 4.
Guideline-Recommended Use
For Stable Ischemic Heart Disease with Hypertension
The American College of Cardiology recommends metoprolol succinate as guideline-directed medical therapy (GDMT) for patients with stable ischemic heart disease and hypertension, targeting blood pressure <130/80 mmHg 5. Metoprolol is specifically listed among the GDMT beta-blockers including metoprolol tartrate, metoprolol succinate, carvedilol, nadolol, bisoprolol, propranolol, and timolol 5.
For Heart Failure with Preserved Ejection Fraction
In patients with HFpEF and persistent hypertension after volume management, beta-blockers including metoprolol should be prescribed and titrated to achieve SBP <130 mmHg 5.
For Hypertensive Cardiomyopathy
The American College of Cardiology recommends metoprolol succinate as a first-line agent for hypertensive cardiomyopathy due to its proven efficacy in reducing mortality, improving cardiac function, and providing consistent 24-hour blood pressure control 6.
Dosing and Administration
The majority of patients with mild to moderate hypertension achieve adequate control with metoprolol 100 mg twice daily 2. The estimated oral bioavailability is approximately 50% due to pre-systemic metabolism 1.
Metoprolol succinate extended-release formulation provides relatively constant plasma concentrations over approximately 20 hours, allowing convenient once-daily administration 7. A 100-mg metoprolol controlled/extended-release tablet contains 95 mg of metoprolol succinate and has equivalent activity to 100 mg metoprolol tartrate 7.
Combination Therapy for Inadequate Response
When metoprolol alone does not achieve blood pressure targets 5:
- Add ACE inhibitors or ARBs as first-line combination therapy for compelling indications such as previous MI or stable angina 5
- Add dihydropyridine calcium channel blockers for patients with angina and persistent uncontrolled hypertension 5
- Add thiazide diuretics and/or mineralocorticoid receptor antagonists as needed for further blood pressure control 5
The combination of metoprolol with chlorthalidone produces statistically significant blood pressure reduction in both supine and standing positions 8.
Important Considerations
Metoprolol's cardioselectivity is clinically important - asthmatics and diabetics tolerate metoprolol extremely well, with side effects occurring in only 15% of patients (mainly gastrointestinal disturbances and dizziness) and leading to treatment withdrawal in only 6.7% 2.
Carvedilol may be preferred over metoprolol for uncomplicated hypertension or hypertension with heart failure due to its combined alpha- and beta-blocking properties and more effective blood pressure reduction 5, 9. Carvedilol is more effective in reducing blood pressure than metoprolol succinate or bisoprolol because of its combined α1-β1-β2-blocking properties 5.
Avoid atenolol - this beta-blocker should not be used because it is less effective than placebo in reducing cardiovascular events 5, 9.