Metoprolol tartrate was more effective than succinate in lowering HR before CCTA, achieving target HR <60 bpm in 67% of patients, with recommended doses of 100 mg for HR >65 bpm.
Does metoprolol reduce heart rate to <60 bpm in patients scheduled for CCTA?
Metoprolol tartrate is more effective than succinate for achieving the target heart rate of <60 bpm prior to CCTA, highlighting common underdosing and supporting doses of 100 mg for most patients with HR >65 bpm.
Abstract Background Coronary computed tomography angiography (CCTA) is recommended as the initial test in patients with stable symptoms suspected of coronary artery disease (CAD) due to its high diagnostic accuracy. Lowering the heart rate (HR) in patients scheduled for CCTA is crucial for both optimal image quality and reducing the radiation dose. Pre-medication with metoprolol is the most common approach to achieve the target HR 60 beats per minute (bpm) during CCTA. However, specific recommendations for metoprolol dosing are lacking. Purpose This study aimed to investigate the dose-response effect of oral metoprolol succinate and tartrate on HR in patients prepared for CCTA and to assess the association between patient characteristics and failure to achieve the target HR 60 bpm. Methods This retrospective study included 4569 consecutive patients scheduled for CCTA between 2022-2023. Patients were categorized based on the applied metoprolol preparation strategy: group 1, no metoprolol; group 2, metoprolol succinate 1-3 days before CCTA; group 3, metoprolol tartrate at the intake of CCTA; group 4, succinate and additional tartrate before CCTA. HR was measured at the outpatient visit (T1), CCTA intake (T2), pre-scan (T3) and during CCTA (T4). Results Patients in group 1 (n=515), group 2 (n=2564), group 3 (n=224), and group 4 (n=1266) demonstrated a mean HR at T4 of 53.4±6.7, 55.6±6.8, 54.8±6.6, and 58.5±6.4 bpm, respectively. The target HR 60 bpm at T4 was achieved in 81% (group 1), 70% (group 2), 79% (group 3), and 54% (group 4) of the patients. In total, 67% of the patients achieved the target HR 60 bpm at T4. Adverse events were low (17/4569; 0.4%) in the total population and none of them required medical intervention. The 3830 patients prepared with metoprolol succinate (groups 2 and 4) received a mean dose of 64±31 mg, had a HR at T1 of 69.0±10.5 bpm and showed a dose-response of -6.2±10.4 bpm from T1-T2. In those patients, only 41% achieved the target HR at T2, and 33% (1266/3830) received additional tartrate at T2 (group 4). Those 1266 patients prepared with succinate and additional tartrate (group 4) demonstrated a reduced dose-response effect of tartrate from T2-T4 compared with patients in group 3 who received tartrate only (-11.8±7.9 versus -15.4±7.9 bpm) despite a similar mean HR at T2 (70.6±6.6 versus 70.2±6.6 bpm) and tartrate dose (72±25 versus 68±24 mg). Female sex, a higher body mass index (BMI), diabetes, and higher baseline HRs were independently associated with failure to achieve the target HR. Conclusion This study demonstrates the dose-response effect of metoprolol on HR before CCTA, highlighting underdosing of both succinate and tartrate, without safety concerns. Tartrate was more effective, particularly in patients without prior succinate preparation. Doses of 100 mg are recommended for most patients with an HR 65 bpm, further guided by patient characteristics.Heart rates during preparation (T1-T4) Graphical abstract
Verpalen et al. (2025) studied this question. Metoprolol tartrate was more effective than succinate in lowering HR before CCTA, achieving target HR <60 bpm in 67% of patients, with recommended doses of 100 mg for HR >65 bpm.