Should we discontinue metoprolol in a 75‑year‑old woman with hypertension, aortic arteriosclerosis, stage 3a chronic kidney disease who now has bradycardia and occasional dizziness with low‑normal blood pressure, and what alternative antihypertensive is recommended?

Management of Bradycardia and Dizziness in Elderly Patient on Metoprolol

You should halve the metoprolol dose to 12.5 mg daily rather than discontinue it abruptly, and consider adding a calcium channel blocker (amlodipine 2.5-5 mg daily) if additional blood pressure control is needed after reassessing in 1-2 weeks. 1

Immediate Beta-Blocker Management

The European Society of Cardiology guidelines provide explicit direction for this exact clinical scenario: when heart rate falls below 50 bpm with worsening symptoms (your patient's dizziness), you should halve the beta-blocker dose rather than stop it entirely. 1

Critical safety consideration: Beta-blockers must never be stopped abruptly due to risk of rebound myocardial ischemia, infarction, and arrhythmias—this is an FDA warning that applies even when adverse effects occur. 1, 2 If discontinuation becomes absolutely necessary, it requires specialist consultation and gradual tapering under close supervision. 1

Specific Dosing Adjustment

• Reduce metoprolol succinate ER from 25 mg to 12.5 mg once daily 1
• Reassess the patient in 1-2 weeks to evaluate symptom resolution 1
• Obtain an ECG to exclude heart block, which would change management 1
• Monitor for improvement in dizziness while tracking blood pressure and heart rate 1

Why Not Complete Discontinuation?

Your patient has multiple compelling indications for beta-blockade (hypertension, arteriosclerosis) and her blood pressure of 109/65 mmHg, while low-normal, does not constitute true symptomatic hypotension requiring drug cessation. 1 The ESC guidelines distinguish between asymptomatic low blood pressure (which requires no intervention) and symptomatic hypotension with dizziness—in the latter case, you first reconsider other vasodilators before stopping the beta-blocker. 1

The bradycardia of 50 bpm with occasional dizziness represents a dose-related adverse effect rather than an absolute contraindication. 1 Elderly patients often tolerate and benefit from beta-blockers at lower doses than younger patients. 1, 3

Alternative Antihypertensive Strategy

If blood pressure rises above target after reducing metoprolol, or if you need additional control:

First-line addition: Amlodipine 2.5-5 mg daily 1

• Dihydropyridine calcium channel blockers are well-tolerated in elderly patients with CKD 1
• They provide effective blood pressure control without affecting heart rate 1
• Start at 2.5 mg in elderly patients to minimize peripheral edema risk 1

Alternative consideration: Low-dose thiazide-like diuretic (chlorthalidone 12.5 mg or indapamide 1.25 mg) 1

• However, monitor closely for electrolyte disturbances and volume depletion in elderly patients with CKD 3a 1
• Thiazides have reduced efficacy when eGFR <30 mL/min but remain effective in CKD 3a 1

What NOT to Use

Avoid these options in your patient:

• ACE inhibitors/ARBs: While generally beneficial, they can exacerbate symptomatic hypotension in elderly patients already experiencing dizziness 1
• Non-dihydropyridine calcium channel blockers (diltiazem, verapamil): These cause bradycardia and would worsen her current problem 1
• Central-acting agents (clonidine, moxonidine): High risk of orthostatic hypotension and falls in elderly patients 1
• Immediate-release nifedipine: Risk of precipitous hypotension 1

Monitoring Plan

After dose reduction, check the following at 1-2 weeks: 1

• Blood pressure (sitting and standing to assess for orthostatic changes)
• Heart rate (target >55 bpm to allow physiologic reserve)
• Symptom resolution (specifically ask about dizziness frequency and severity)
• Renal function (creatinine, eGFR given CKD 3a baseline) 1

If symptoms persist despite dose reduction, then consider specialist cardiology referral before making further changes. 1

Special Considerations for CKD 3a

Metoprolol succinate is primarily hepatically metabolized, making it preferable to atenolol in patients with kidney dysfunction. 4 Your patient's CKD 3a does not require dose adjustment for metoprolol specifically, but it does increase her vulnerability to volume depletion and electrolyte disturbances if you add diuretics. 1

The combination of age, CKD, and cardiovascular disease places her at higher risk for adverse drug effects, supporting the strategy of using lower doses of multiple agents rather than high doses of single agents. 1