What is the maximum daily dose of metoprolol (tartrate and succinate) for hypertension, angina, post‑myocardial infarction, and chronic heart failure?

Maximum Daily Dose of Metoprolol

For hypertension and angina, the maximum dose is metoprolol tartrate 200 mg twice daily (400 mg total per day) or metoprolol succinate 400 mg once daily; for heart failure, the target dose is metoprolol succinate 200 mg once daily. 1, 2

Formulation-Specific Maximum Doses

Metoprolol Tartrate (Immediate-Release)

• Maximum: 200 mg twice daily (400 mg total per day) for hypertension and chronic maintenance therapy 1
• Initial dosing: 25–50 mg twice daily, titrated every 1–2 weeks based on blood pressure and heart rate response 1
• For acute IV administration, the ceiling is 15 mg total (three 5 mg boluses given 5 minutes apart) 1

Metoprolol Succinate (Extended-Release)

• Maximum: 400 mg once daily for hypertension and atrial fibrillation rate control 1, 2
• Target dose: 200 mg once daily for heart failure with reduced ejection fraction (HFrEF), which is the evidence-based dose from the MERIT-HF trial 2, 3
• Initial dosing: 25–50 mg once daily for hypertension; 12.5–25 mg once daily for heart failure 2

Indication-Specific Dosing

Hypertension

• Metoprolol tartrate: start 25–50 mg twice daily, maximum 200 mg twice daily 1
• Metoprolol succinate: start 50 mg once daily, titrate to 50–400 mg once daily 1
• Titration interval: every 1–2 weeks based on blood pressure response 1

Angina Pectoris

• Target dose: 200 mg daily (either formulation) 2
• Titrate gradually every 1–2 weeks as tolerated 2

Post-Myocardial Infarction

• After initial IV therapy (maximum 15 mg), start oral metoprolol tartrate 50 mg every 6 hours for 48 hours 1
• Maintenance: metoprolol succinate 200 mg once daily for secondary prevention 1

Heart Failure with Reduced Ejection Fraction

• Target dose: metoprolol succinate 200 mg once daily (this is the mortality-reducing dose from MERIT-HF) 2, 3
• Initial dose: 12.5–25 mg once daily 2
• Titration: double the dose every 1–2 weeks if well tolerated 2
• Mean dose achieved in clinical trials: 159 mg daily 1
• At least 50% of target dose (100 mg daily) should be achieved for optimal outcomes 1

Atrial Fibrillation Rate Control

• Metoprolol tartrate: 25–100 mg twice daily, maximum 200 mg twice daily 1
• Metoprolol succinate: 50–400 mg once daily 1
• Target resting heart rate: 50–80 bpm (strict control) or <110 bpm (lenient control) 1

Absolute Contraindications at Any Dose

Before prescribing any dose of metoprolol, verify the absence of:

• Signs of heart failure, low output state, or decompensated heart failure 1
• Second- or third-degree AV block without a functioning pacemaker 1
• PR interval >0.24 seconds 1
• Active asthma or severe reactive airway disease 1
• Symptomatic bradycardia (heart rate <50–60 bpm with symptoms) 1
• Systolic blood pressure <100 mmHg with symptoms 1
• Cardiogenic shock 1

Critical Formulation Distinction for Heart Failure

Metoprolol succinate (extended-release) is the ONLY formulation proven to reduce mortality in heart failure. 2, 3 The MERIT-HF trial demonstrated a 34% reduction in all-cause mortality, 41% reduction in sudden death, and 49% reduction in death from progressive heart failure with metoprolol succinate 200 mg once daily. 3 Metoprolol tartrate showed inferior outcomes compared to carvedilol in the COMET trial and is NOT the evidence-based formulation for heart failure. 2

Common Pitfall to Avoid

Never prescribe metoprolol succinate twice daily—this deviates from the evidence-based once-daily dosing used in mortality-reduction trials. 2 Metoprolol tartrate 50 mg twice daily is commonly prescribed but was neither the dose nor formulation that showed mortality benefit in heart failure. 2

Monitoring During Titration

• Check heart rate, blood pressure, and clinical status at each visit 2
• Watch for worsening heart failure symptoms (increased dyspnea, edema, weight gain) 1
• Monitor for symptomatic hypotension (systolic BP <85–100 mmHg with dizziness) 1, 2
• Assess for symptomatic bradycardia (heart rate <50–60 bpm with symptoms) 1
• Listen for bronchospasm, especially in patients with any history of reactive airway disease 1

Discontinuation Warning

Never abruptly discontinue metoprolol—sudden cessation can precipitate severe angina, myocardial infarction, ventricular arrhythmias, and a 2.7-fold increased risk of 1-year mortality. 1 If discontinuation is necessary, taper the dose by approximately 25–50% every 1–2 weeks. 1