Can a patient with hypertension continue on metoprolol (beta blocker) or should they be switched to an alternative antihypertensive medication such as an ACE (angiotensin-converting enzyme) inhibitor, ARB (angiotensin II receptor blocker), or calcium channel blocker?

Can Metoprolol Be Continued for Hypertension?

Metoprolol should generally be switched to a first-line antihypertensive agent (ACE inhibitor, ARB, thiazide diuretic, or calcium channel blocker) unless the patient has a compelling indication such as coronary artery disease, heart failure with reduced ejection fraction, or recent myocardial infarction. 1

Why Beta-Blockers Are Not First-Line for Uncomplicated Hypertension

• Beta-blockers are no longer recommended as initial therapy for uncomplicated hypertension because they do not reduce cardiovascular events as effectively as other first-line agents. 1, 2

• The 2017 ACC/AHA guidelines explicitly state that first-line therapy should consist of ACE inhibitors, ARBs, thiazide diuretics, or calcium channel blockers for most patients with hypertension. 1

• Beta-blockers like metoprolol are reserved for patients with specific compelling indications where they provide mortality benefit beyond blood pressure control alone. 1

When Metoprolol Should Be Continued

Continue metoprolol if the patient has any of these conditions:

• Coronary artery disease or stable ischemic heart disease: Beta-blockers are guideline-directed therapy and should be combined with ACE inhibitors or ARBs as first-line treatment. 1

• History of myocardial infarction: It is reasonable to continue beta-blockers beyond 3 years post-MI for long-term hypertension management. 1

• Heart failure with reduced ejection fraction (HFrEF): Use sustained-release metoprolol succinate (not metoprolol tartrate), carvedilol, or bisoprolol, as these three specific beta-blockers reduce mortality in heart failure. 1

• Symptomatic angina: Beta-blockers provide symptom relief and should be continued, with dihydropyridine calcium channel blockers added if blood pressure remains uncontrolled. 1

Recommended Switch Strategy for Uncomplicated Hypertension

If the patient has no compelling indications, transition to first-line therapy:

1. Start an ACE inhibitor or ARB (preferred for most patients, especially those with diabetes or chronic kidney disease). 1, 2

2. Alternative: Start a thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide, particularly effective in Black patients and elderly patients). 2, 3

3. Alternative: Start a calcium channel blocker (amlodipine or other dihydropyridine, particularly effective in Black patients and elderly patients). 1, 2

4. Gradually taper metoprolol over 1-2 weeks while initiating the new agent, as abrupt discontinuation can cause rebound hypertension and, in patients with unrecognized coronary disease, may precipitate angina or myocardial infarction. 4

Special Consideration: Carvedilol vs. Metoprolol

• If a beta-blocker is needed for refractory hypertension in a patient with heart failure, carvedilol is more effective at lowering blood pressure than metoprolol succinate or bisoprolol due to its combined α1-β1-β2 blocking properties. 1

Target Blood Pressure

• Aim for blood pressure <130/80 mmHg in most patients with hypertension, including those with coronary artery disease, heart failure, or chronic kidney disease. 1, 5

Critical Pitfalls to Avoid

• Never abruptly discontinue metoprolol in patients with known or suspected coronary artery disease, as this can precipitate severe angina, myocardial infarction, or ventricular arrhythmias. 4

• Do not use metoprolol as monotherapy for uncomplicated hypertension when superior first-line options are available. 1, 2

• Avoid combining beta-blockers with non-dihydropyridine calcium channel blockers (verapamil, diltiazem) due to risk of severe bradycardia and heart block. 1

• In patients with heart failure, ensure you use one of the three mortality-reducing beta-blockers (metoprolol succinate, carvedilol, or bisoprolol) rather than metoprolol tartrate. 1