Should the evening dose of metoprolol (beta-blocker) 25 mg be held in a patient with diastolic heart failure, paroxysmal atrial fibrillation, impaired renal function requiring dialysis, and current hypotension with a mean arterial pressure (MAP) of 55?

Should the Evening Dose of Metoprolol Be Held?

Yes, hold the evening dose of metoprolol 25 mg in this patient with a mean arterial pressure of 55 mmHg and diastolic blood pressure of 35 mmHg, as symptomatic hypotension (MAP <60-65 mmHg) and diastolic BP <40 mmHg represent absolute contraindications to continued beta-blocker therapy. 1, 2

Immediate Assessment Required

Critical hemodynamic parameters to evaluate:

• Assess for signs of hypoperfusion: Check for oliguria, altered mental status, cool extremities, or other evidence of inadequate tissue perfusion 1
• Evaluate volume status: Determine if the patient has signs of decompensated heart failure (rales, elevated JVP, peripheral edema) versus hypovolemia 3, 1
• Rule out acute causes: Consider sepsis (which can present with fever and hypotension), acute bleeding, or other reversible causes of hypotension 1

Guideline-Based Contraindications

The current hemodynamic status meets multiple absolute contraindications for beta-blocker administration:

• Symptomatic hypotension with systolic BP <100 mmHg is an absolute contraindication to metoprolol 1, 2
• The European Heart Journal identifies symptomatic bradycardia or hypotension as contraindications to beta-blocker therapy 3
• Signs of low cardiac output or decompensated heart failure require holding metoprolol 1, 2

Management Strategy After Holding the Dose

Immediate interventions (in order of priority):

1. Address reversible causes first: Optimize volume status with IV fluids if hypovolemic, or increase diuretics if volume overloaded 1
2. Adjust other antihypertensive medications: Reduce or temporarily hold ACE inhibitors or other vasodilators that may be contributing to hypotension 3, 1
3. Monitor closely: Check blood pressure and heart rate every 4-6 hours initially 1

Reintroduction Protocol When Hemodynamically Stable

Do not abruptly discontinue metoprolol permanently, as this increases mortality risk 2.7-fold in patients with coronary disease or heart failure. 1, 2

Criteria for restarting metoprolol:

• Systolic blood pressure consistently >100 mmHg without symptoms 1
• Heart rate >55-60 bpm 1
• No signs of hypoperfusion or decompensated heart failure 3, 1

Restart protocol:

• Begin with metoprolol 12.5 mg once daily (50% dose reduction from current 25 mg) 1, 4
• Monitor blood pressure and heart rate at each visit 1
• Titrate slowly over weeks only if hemodynamics remain stable 1, 4

Special Considerations for This Patient

Paroxysmal atrial fibrillation management:

• Beta-blockers remain first-line for rate control in AF with compensated heart failure 1
• Consider diltiazem 120-360 mg daily as an alternative if metoprolol cannot be reintroduced due to persistent hypotension 1
• Avoid diltiazem if the patient has decompensated heart failure or severe LV dysfunction 3, 1

Diastolic heart failure considerations:

• Beta-blockers provide mortality benefit in heart failure with reduced ejection fraction 4, 5
• Maintaining some beta-blockade is preferable to complete discontinuation when hemodynamically feasible 1, 4

Renal dysfunction and dialysis:

• Metoprolol CR/XL was at least as effective in reducing death and hospitalizations in patients with eGFR <45 as in those with eGFR >60 6
• Renal dysfunction does not require dose adjustment of metoprolol, but increases the importance of careful hemodynamic monitoring 6

Critical Pitfalls to Avoid

• Never restart metoprolol at the previous dose without ensuring hemodynamic stability 1, 2
• Do not assume hypotension is solely due to metoprolol—rule out sepsis, bleeding, and other acute causes 1
• Avoid complete permanent discontinuation if possible, as this significantly increases mortality risk 1, 2
• Do not use IV fluids aggressively if the patient has volume overload or decompensated heart failure 1