How should we manage a hypertensive adult who was stable on metoprolol succinate 25 mg daily, now off the medication after moving to a new state and presenting with severe hypertension?

Management of Severe Hypertension After Discontinuation of Metoprolol Succinate

This patient should be immediately restarted on metoprolol succinate 25 mg daily, with urgent follow-up within 1 month to assess blood pressure control and titrate therapy as needed. 1

Immediate Pharmacological Intervention

Restart Beta-Blocker Therapy

• Metoprolol succinate 25 mg once daily should be reinitiated immediately given the patient's prior stability on this regimen and current severe hypertension 1, 2
• Metoprolol succinate is specifically recommended as guideline-directed medical therapy (GDMT) for hypertension, with proven cardiovascular benefits including blood pressure control 1
• The once-daily extended-release formulation (metoprolol succinate) provides superior adherence compared to twice-daily metoprolol tartrate and has demonstrated mortality benefits in cardiovascular disease 2

Rationale for Beta-Blocker Selection

• Beta-blockers are Class I recommended antihypertensive agents, particularly metoprolol succinate, carvedilol, and bisoprolol 1
• Given this patient was previously well-controlled on metoprolol succinate 25 mg, restarting the same medication capitalizes on known efficacy and tolerability 3, 4
• Metoprolol succinate provides 24-hour blood pressure control with once-daily dosing, improving medication adherence 4, 5

Urgent Follow-Up and Monitoring

Timeline for Reassessment

• Patients with severe hypertension (≥160/100 mm Hg) require evaluation within 1 month with prompt treatment initiation and careful monitoring 1
• Blood pressure should be rechecked within 2-4 weeks after restarting therapy to assess response and adjust dosing 1
• If blood pressure remains uncontrolled at 1-month follow-up, escalation to combination therapy is indicated 1

Dose Titration Strategy

• If blood pressure is not controlled on metoprolol succinate 25 mg after 1 month, increase to 50 mg daily, then up to 200 mg daily as tolerated 1, 2
• Metoprolol demonstrates dose-related blood pressure reductions across the therapeutic range of 25-400 mg daily 3

Combination Therapy if Monotherapy Insufficient

Second-Line Agent Selection

• If blood pressure remains uncontrolled after optimizing metoprolol dose, add either an ACE inhibitor/ARB, calcium channel blocker, or thiazide-like diuretic 1
• The 2024 ESC guidelines recommend upfront combination therapy for confirmed hypertension, but given this patient's prior control on monotherapy, restarting single-agent therapy is reasonable 1
• Low-dose combination therapy (metoprolol with a calcium channel blocker or diuretic) provides additive blood pressure lowering effects 3

Preferred Combinations

• Metoprolol succinate combined with a dihydropyridine calcium channel blocker (e.g., amlodipine, felodipine) provides complementary mechanisms and additive efficacy 3
• Alternatively, combining metoprolol with a thiazide-like diuretic (chlorthalidone preferred) or ACE inhibitor/ARB is effective 1
• Single-pill combinations are preferred when combination therapy is needed to improve adherence 1

Blood Pressure Goals

Target Blood Pressure

• The target blood pressure is <130/80 mm Hg for adults with hypertension 1
• This target is based on strong evidence from trials like SPRINT showing reduced cardiovascular events and heart failure with intensive blood pressure control 1

Critical Safety Considerations

Contraindications to Avoid

• Do not restart metoprolol if the patient has developed signs of heart failure, evidence of low output state, increased risk for cardiogenic shock, PR interval >0.24 seconds, second- or third-degree heart block, or active asthma/reactive airways disease 1
• Monitor for bradycardia (heart rate <60 bpm) and hypotension (systolic BP <90 mm Hg) after restarting therapy 1

Adherence Assessment

• Given the patient was taken off metoprolol by another provider, ensure clear communication about the importance of continuing this medication 1
• The patient's emotional distress and denial of dental care due to severe hypertension underscore the urgency of treatment 1

Addressing the Dental Care Issue

Blood Pressure Stabilization for Procedures

• Most dental offices defer elective procedures when blood pressure is ≥180/110 mm Hg due to increased procedural risk 1
• Once blood pressure is controlled to <160/100 mm Hg (ideally <130/80 mm Hg), dental care can proceed safely 1
• Provide documentation of blood pressure control and ongoing management to facilitate dental treatment 1

Provider Coordination

Establishing Continuity of Care

• While providing a short-term prescription (1-3 months) is appropriate to bridge care, the patient must establish with a local primary care provider for ongoing management 1
• Provide clear documentation of prior treatment regimen, blood pressure history, and current management plan to the new provider 1
• Consider telehealth follow-up if the patient has difficulty accessing local care in the interim 1