Metoprolol Hold Parameters
Hold metoprolol if heart rate is <45 bpm, systolic blood pressure is <100 mmHg, or the patient has symptomatic bradycardia (HR <50-60 bpm with dizziness, lightheadedness, or syncope). 1, 2
Primary Hold Parameters
Heart Rate Thresholds
- Absolute contraindication: HR <45 bpm - This is an FDA-labeled contraindication for metoprolol administration 1
- Symptomatic bradycardia: HR <50-60 bpm with symptoms (dizziness, lightheadedness, syncope, altered mental status) requires holding the medication 2
- Perioperative context: Hold if HR consistently <45 bpm, or delay 12 hours if HR 45-49 bpm 2
Blood Pressure Thresholds
- Absolute contraindication: Systolic BP <100 mmHg - This is an FDA-labeled contraindication 1
- Symptomatic hypotension: SBP <100 mmHg with symptoms (dizziness, lightheadedness, blurred vision, signs of hypoperfusion) requires holding 2
- High-risk threshold: SBP <120 mmHg in acute MI patients increases cardiogenic shock risk 2
Heart Rate Upper Limit
- Sinus tachycardia >110 bpm in acute MI patients is a contraindication due to increased cardiogenic shock risk 2
Additional Absolute Contraindications
Beyond vital sign parameters, hold metoprolol for:
- Cardiac conduction abnormalities: Second or third-degree heart block, PR interval ≥0.24 seconds, significant first-degree heart block 1, 2
- Heart failure: Signs of decompensated heart failure, low output state, moderate-to-severe cardiac failure 1, 2
- Respiratory: Active asthma or reactive airway disease 2
- Hemodynamic instability: Evidence of cardiogenic shock or increased risk factors 2
Critical Monitoring During Administration
When administering metoprolol (especially IV), monitor continuously for:
- Heart rate and blood pressure every 5 minutes during IV dosing 2
- Auscultation for rales (pulmonary congestion) 2
- Auscultation for bronchospasm 2
- Signs of hypoperfusion (oliguria, altered mental status, cool extremities) 2
Dose Reduction vs. Complete Hold
Reduce dose by 50% rather than holding completely when:
- HR 50-60 bpm without symptoms 2
- SBP 100-110 mmHg without symptoms 2
- Patient has underlying coronary disease or heart failure where abrupt discontinuation carries 2.7-fold increased mortality risk 2
Hold completely when:
- HR <45 bpm or symptomatic bradycardia 1, 2
- SBP <100 mmHg with symptoms 2
- Signs of decompensated heart failure develop 2
- Evidence of high-grade AV block 2
Common Pitfall to Avoid
Never abruptly discontinue metoprolol - Abrupt cessation can cause severe exacerbation of angina, myocardial infarction, ventricular arrhythmias, and carries a 50% mortality rate in some studies 2. If discontinuation is necessary, taper by 25-50% every 1-2 weeks while monitoring closely for worsening symptoms 2.