How should metoprolol be initiated and titrated in an adult with hypertension, angina, atrial arrhythmias, or chronic heart failure, including starting dose, titration increments and intervals, target heart rate and systolic blood pressure, monitoring for bradycardia, hypotension, heart‑failure worsening, and special considerations for elderly or hepatic impairment?

How to Initiate and Titrate Metoprolol

Start metoprolol tartrate at 25–50 mg twice daily (or metoprolol succinate 25–50 mg once daily) and titrate by doubling the dose every 1–2 weeks until you reach the target dose of 200 mg daily, monitoring heart rate (target 50–60 bpm), systolic blood pressure (maintain ≥100 mmHg), and signs of worsening heart failure at each visit. 1

Starting Dose Selection

Choose your formulation and initial dose based on the clinical indication:

• Hypertension: Metoprolol tartrate 25–50 mg twice daily OR metoprolol succinate 50 mg once daily 1
• Angina pectoris: Metoprolol tartrate 25–50 mg twice daily, transitioning to twice-daily dosing over 2–3 days 1
• Atrial arrhythmias (rate control): Metoprolol tartrate 25–50 mg twice daily OR metoprolol succinate 50 mg once daily 1
• Heart failure with reduced ejection fraction (HFrEF): Metoprolol succinate 12.5–25 mg once daily (use the lower dose in elderly or frail patients) 1, 2

Critical formulation distinction: Only metoprolol succinate extended-release has proven mortality reduction in heart failure; never substitute metoprolol tartrate for this indication. 2, 3

Absolute Contraindications (Must Rule Out Before Starting)

Do not initiate metoprolol if any of the following are present:

• Signs of heart failure, low output state, or decompensated heart failure (pulmonary rales, peripheral edema, acute dyspnea) 1
• PR interval >0.24 seconds or second/third-degree AV block without a functioning pacemaker 1
• Active asthma or reactive airways disease with current bronchospasm 1
• Systolic blood pressure <100 mmHg with symptoms 1
• Heart rate <60 bpm (or >110 bpm in acute settings, which increases cardiogenic shock risk) 1
• Cardiogenic shock or risk factors: age >70 years, systolic BP <120 mmHg, sinus tachycardia >110 bpm 1

Titration Protocol

Standard titration schedule (every 1–2 weeks if tolerated):

For Hypertension or Angina:

• Week 0: 25–50 mg twice daily (tartrate) or 50 mg once daily (succinate) 1
• Week 2: 50 mg twice daily (tartrate) or 100 mg once daily (succinate) 1
• Week 4: 100 mg twice daily (tartrate) or 200 mg once daily (succinate) 1
• Maximum: 200 mg twice daily (tartrate) or 400 mg once daily (succinate) 1

For Heart Failure (HFrEF):

• Week 0: 12.5–25 mg once daily (succinate only) 1, 2
• Week 2: 25 mg once daily 1
• Week 4: 50 mg once daily 1
• Week 6: 100 mg once daily 1
• Week 8: Target 200 mg once daily 1, 2

If the target dose cannot be reached, maintain at least 50% of target (100 mg daily for HFrEF) to preserve mortality benefit. 1, 2

Monitoring Parameters at Each Visit

Heart Rate:

• Target resting heart rate: 50–60 bpm (unless limiting side effects occur) 1
• Hold or reduce dose if heart rate <50 bpm with symptoms (dizziness, lightheadedness, syncope) 1
• Symptomatic bradycardia is an absolute contraindication to continued therapy 1

Blood Pressure:

• Maintain systolic BP ≥100 mmHg 1
• Asymptomatic low BP does not require adjustment 1
• Hold dose if systolic BP <100 mmHg with symptoms (dizziness, altered mental status, hypoperfusion) 1

Signs of Worsening Heart Failure:

• Auscultate lungs for new rales (pulmonary congestion) 1
• Check for peripheral edema and weight gain (>1.5–2 kg over 2 days) 1
• Assess for increased dyspnea, fatigue, or reduced exercise tolerance 1

Bronchospasm:

• Listen for wheezing, especially in patients with any history of reactive airway disease 1

Managing Adverse Effects During Titration

Worsening Heart Failure or Fluid Retention:

1. First: Increase diuretic dose 1
2. Second: Temporarily reduce metoprolol by 50% only if diuretic escalation fails 1
3. Third: Once stabilized, re-escalate metoprolol toward target 1

Symptomatic Hypotension:

1. First: Reduce or eliminate vasodilators (nitrates, calcium channel blockers) 1
2. Second: Reduce diuretic dose if no signs of congestion 1
3. Third: Temporarily reduce metoprolol only if above measures fail 1

Symptomatic Bradycardia (<50 bpm with symptoms):

1. First: Reduce or stop other rate-lowering drugs (digoxin, diltiazem, verapamil, amiodarone) 1
2. Second: Reduce metoprolol dose by 50% 1
3. Never abruptly discontinue: Sudden withdrawal causes a 2.7-fold increased risk of 1-year mortality, plus severe angina exacerbation, MI, and ventricular arrhythmias 1

Special Populations

Elderly Patients (≥65 years):

• Start at the lower end of the dosing range: 12.5–25 mg daily 1
• Extend titration intervals to 2–4 weeks if transient side effects develop 1
• Monitor closely for orthostatic hypotension, falls, and bradycardia 1

Hepatic Impairment:

• Start with lower doses (12.5–25 mg) due to reduced first-pass metabolism and higher drug exposure 1
• Titrate more cautiously with extended intervals 1

Women:

• Consider 50% dose reduction on average, as metoprolol exposure is 50–80% higher in women than men 1
• Women with HFrEF may achieve optimal outcomes at 50% of guideline-recommended doses 1

Common Pitfalls to Avoid

• Do not use metoprolol tartrate for heart failure: Only succinate extended-release has mortality benefit 2, 3
• Do not give IV metoprolol in decompensated heart failure: The COMMIT trial showed an 11-per-1,000 increase in cardiogenic shock 1
• Do not abruptly discontinue: Taper gradually over ~1 week to prevent rebound ischemia, MI, and arrhythmias (50% mortality in one study) 1
• Do not underdose: Fewer than 25% of real-world patients reach target doses, yet higher doses confer greater mortality reduction 1, 2
• Do not administer to patients with active asthma: Even cardioselective beta-blockers can precipitate bronchospasm at therapeutic doses 1

When to Seek Specialist Consultation

• Severe (NYHA class IV) heart failure before initiating beta-blocker 1
• Persistent symptomatic bradycardia or hypotension despite dose adjustments 1
• Inability to tolerate even minimal doses (12.5 mg) 1
• Need for permanent pacemaker evaluation (high-grade AV block) 1