What is the recommended dose of metoprolol (beta blocker) for hypertension, angina, and heart failure?

Metoprolol Dosing for Hypertension, Angina, and Heart Failure

For hypertension, start metoprolol tartrate at 25-50 mg twice daily (maximum 200 mg/day) or metoprolol succinate extended-release at 50-200 mg once daily (maximum 400 mg/day); for angina, use 100-400 mg daily in divided doses; for heart failure with reduced ejection fraction, initiate metoprolol succinate extended-release at 12.5-25 mg once daily and titrate to a target of 200 mg once daily. 1

Hypertension Dosing

Initial Dosing

• Metoprolol tartrate (immediate-release): Start at 25-50 mg twice daily 1
• Metoprolol succinate (extended-release): Start at 50-200 mg once daily 1

Maximum Doses

• Metoprolol tartrate: 200 mg daily 1
• Metoprolol succinate: 400 mg daily 1

Titration Strategy

• Increase dosage gradually every 1-2 weeks if blood pressure control is not achieved 1
• Target blood pressure reduction should be at least 20/10 mmHg, ideally to <140/90 mmHg 1
• Monitor blood pressure and heart rate at each visit, targeting a resting heart rate of 50-60 beats per minute unless limiting side effects occur 1

Angina Pectoris Dosing

• Effective dosage range: 100-400 mg daily administered orally two or four times daily 2
• Metoprolol tartrate 25-50 mg twice daily initially, with titration to 200 mg daily as tolerated 1
• The drug has been shown to reduce the number of angina attacks and increase exercise tolerance 2

Heart Failure with Reduced Ejection Fraction (HFrEF)

Critical Formulation Requirement

Only metoprolol succinate extended-release (CR/XL) should be used for heart failure—metoprolol tartrate has not demonstrated mortality reduction and should NOT be used for this indication. 3

Starting Dose

• Initial dose: 12.5-25 mg once daily, depending on heart failure severity 1, 3
• For more severe heart failure, start at 12.5 mg once daily 1

Titration Schedule

• Double the dose every 2 weeks as tolerated 1, 3
• Typical progression: 12.5 mg → 25 mg → 50 mg → 100 mg → 200 mg once daily 1, 3

Target Dose

• Target dose: 200 mg once daily 1, 3
• This target dose achieved a 34% reduction in all-cause mortality in the MERIT-HF trial 3, 4
• If full target cannot be achieved, aim for at least 50% of target dose (100 mg daily minimum), as dose-response relationships exist for mortality benefit 1

Clinical Benefits

• 34% decrease in all-cause mortality 3
• 38% decrease in cardiovascular mortality 3
• 41% decrease in sudden death 3
• 49% decrease in death from progressive heart failure 3
• 35% reduction in hospitalization due to heart failure 3

Acute Myocardial Infarction

Early IV Treatment

• Initial IV dose: 5 mg over 1-2 minutes 1
• Repeat every 5 minutes as needed, up to a maximum total dose of 15 mg 1
• Monitor blood pressure, heart rate, and ECG continuously during IV administration 1, 2

Transition to Oral Therapy

• In patients who tolerate the full IV dose (15 mg), initiate metoprolol tartrate 50 mg every 6 hours, starting 15 minutes after the last IV dose 2
• Continue 50 mg every 6 hours for 48 hours 2
• Thereafter, maintenance dosage is 100 mg orally twice daily 2

Critical Contraindications Before IV Administration

Do NOT administer IV metoprolol if any of the following are present: 1

• Signs of heart failure, low output state, or increased risk for cardiogenic shock
• Systolic BP <120 mmHg
• Heart rate >110 bpm or <60 bpm
• PR interval >0.24 seconds
• Second or third-degree heart block
• Active asthma or reactive airways disease
• Age >70 years (relative contraindication—use with extreme caution)

Special Populations

Elderly Patients (>65 years)

• Initiate at low doses with cautious gradual titration 2
• 100 mg daily may be sufficient for hypertension control in elderly patients 5
• Metoprolol 15 mg in elderly women produces similar drug exposure to 50 mg in healthy young men 1

Women

• Women may achieve optimal outcomes at 50% of guideline-recommended doses 1
• Metoprolol exposure is 50-80% higher in women than men 1
• Consider starting at lower doses and titrating more cautiously 1

Hepatic Impairment

• Initiate at low doses with cautious gradual titration according to clinical response 2
• Elimination half-life is considerably prolonged (up to 7.2 hours) in hepatic impairment 2

Renal Impairment

• No dose adjustment required 2
• Systemic availability and half-life do not differ clinically from normal subjects 2

Monitoring Parameters

During Initiation and Titration

• Blood pressure and heart rate at each visit 1
• Target resting heart rate: 50-60 beats per minute 1
• Signs of worsening heart failure or bronchospasm 1
• For heart failure patients: daily weights (increase diuretic if weight increases by 1.5-2.0 kg over 2 days) 3

During IV Administration

• Continuous ECG monitoring 1
• Frequent heart rate and blood pressure checks 1
• Auscultation for rales (pulmonary congestion) 1
• Auscultation for bronchospasm 1

Common Pitfalls to Avoid

Never Abruptly Discontinue

• Abrupt cessation can cause severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias with 50% mortality rate 1
• Beta-blocker withdrawal is associated with 2.7-fold increased risk of 1-year mortality 1
• If discontinuation is necessary, taper gradually over approximately one week under close surveillance 3

Wrong Formulation for Heart Failure

• Only metoprolol succinate extended-release (CR/XL) has proven mortality benefit in heart failure 3
• Metoprolol tartrate should NOT be used for heart failure 3

Rapid IV Bolus

• Never give the full 15 mg IV dose rapidly or as a single bolus—this significantly increases hypotension and bradycardia risk 1
• Always administer slowly over 1-2 minutes per 5 mg dose 1

Underdosing in Heart Failure

• Many clinicians maintain patients on suboptimal doses due to fear of side effects 3
• Aim for target dose of 200 mg daily or at least 50% of target (100 mg daily) 1, 3
• Some beta-blocker is better than no beta-blocker, even at lower doses 3