At what systolic blood pressure should metoprolol tartrate (metoprolol) be held in patients with a history of hypertension or cardiovascular disease to mitigate the risk of hypotension?

Metoprolol Tartrate Hold Parameters for Systolic Blood Pressure

Hold metoprolol tartrate when systolic blood pressure falls below 100 mmHg, particularly if accompanied by symptoms of hypotension such as dizziness, lightheadedness, or altered mental status. 1, 2

Primary Hold Threshold

• The critical systolic blood pressure threshold is <100 mmHg with symptoms 2
• For IV administration specifically, systolic BP <120 mmHg is considered a contraindication in acute settings like myocardial infarction 1, 2
• Symptomatic hypotension (systolic BP <100-120 mmHg with dizziness, lightheadedness, or signs of hypoperfusion) requires immediate medication hold 1

Clinical Context Matters

The hold parameters differ based on clinical scenario:

Acute/IV Administration Settings

• Systolic BP <120 mmHg is an absolute contraindication for IV metoprolol in acute coronary syndromes 1, 2
• This higher threshold (120 mmHg) applies when considering IV bolus dosing, as the risk of cardiogenic shock increases significantly below this level 1

Chronic Oral Therapy

• Hold when systolic BP <100 mmHg with symptoms (dizziness, lightheadedness, syncope, altered mental status) 2
• Asymptomatic readings between 100-110 mmHg may warrant dose reduction rather than complete hold, particularly in patients with compelling indications like heart failure or post-MI status 2

Additional Critical Hold Parameters Beyond Blood Pressure

While the question focuses on systolic BP, these concurrent findings mandate holding metoprolol regardless of blood pressure:

• Symptomatic bradycardia (HR <50-60 bpm with symptoms) is an absolute contraindication 1, 2
• Signs of decompensated heart failure (new or worsening rales, low output state) 1, 2
• Second or third-degree AV block without a functioning pacemaker 1, 2
• Active bronchospasm or severe asthma exacerbation 1, 2

Monitoring Protocol When Near Threshold

• Check blood pressure before each dose 1
• Assess for symptoms of hypoperfusion: oliguria, cool extremities, altered mental status, dizziness 2
• Monitor heart rate concurrently, as combined bradycardia and hypotension significantly increases risk 2

Common Clinical Pitfall

Never abruptly discontinue metoprolol even when holding doses, as this can cause severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias with up to 50% mortality in some studies 2. If blood pressure remains low, consider dose reduction (50% decrease) rather than complete cessation, particularly in patients with coronary disease or heart failure 2.

Target Blood Pressure Range for Continuation

• Current guidelines recommend treating systolic BP to 120-129 mmHg in most adults when well tolerated 3
• For patients ≥65 years, target systolic BP of 130-139 mmHg 3
• The "as low as reasonably achievable" (ALARA) principle applies when target BP cannot be reached due to intolerance 3