Inadvertent metoprolol tartrate overdose (50 mg every 4 hours) resulted in SCAI Stage C cardiogenic shock in a 78-year-old female, which was successfully managed with pacing and epinephrine.
Case Report (n=1)
Early recognition and aggressive treatment with pacing and vasopressors can successfully manage life-threatening cardiogenic shock resulting from metoprolol overdose.
Abstract Introduction Metoprolol toxicity is often underrecognized due to its ability to masquerade as other causes of hemodynamic instability. Delayed recognition increases mortality given its rapid progression to cardiovascular collapse and limited response to conventional therapies. Case 78-year-old female with hypertension, heart failure with preserved ejection fraction, and paroxysmal atrial fibrillation—status post ablation two days prior—presented with acute dyspnea and altered mentation. She was hypothermic, bradycardic (30s), hypotensive (96/58 mm Hg), and hypoxemic. Labs showed markedly elevated transaminases consistent with shock liver; venous blood gas revealed severe respiratory acidosis (pH 7.10, pCO2 78 mmHg). Electrocardiogram demonstrated complete heart block and chest radiograph showed pulmonary edema. She was intubated for respiratory failure. Family confirmed she had been inadvertently taking metoprolol tartrate 50 mg every 4 hours for the preceding 36 hours. Given her SCAI Stage C cardiogenic shock, she was transvenously paced and given epinephrine infusions. Over the next 48 hours, she demonstrated hemodynamic improvement, was weaned off vasopressor support, and successfully extubated. Discussion Metoprolol overdose is a rare but life-threatening cause of cardiogenic shock requiring advanced hemodynamic support. Doses exceeding 250 mg within 24 hours can precipitate atrioventricular block and impair contractility due to excessive β1-adrenergic blockade and a washout period of at least 48 hours is required. Treatment includes vasopressors or, in refractory cases, veno-arterial extracorporeal membrane oxygenation. Epinephrine provides α1 and β1-adrenergic stimulation, increasing myocardial contractility and cardiac output. In this case, early recognition and timely interventions with pacing, vasopressors, and supportive care facilitated recovery. Conclusion Early recognition of metoprolol toxicity is critical, as delayed diagnosis can lead to poor outcomes. This case highlights the need to ensure a high index of suspicion for beta-blocker overdose in bradycardic, hypotensive patients especially in the setting of recent procedural medication changes. This abstract is funded by: None
Kacheria et al. (Fri,) conducted a case report in Metoprolol overdose and cardiogenic shock (n=1). Metoprolol tartrate was evaluated. Inadvertent metoprolol tartrate overdose (50 mg every 4 hours) resulted in SCAI Stage C cardiogenic shock in a 78-year-old female, which was successfully managed with pacing and epinephrine.
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