Guidelines recommend an evidence-based beta blocker in combination with an angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker (ARB), or angiotensin receptor-neprilysin inhibitor (ARNI) and aldosterone antagonist, in select patients, for patients with chronic reduced ejection fraction heart failure (HFrEF) to reduce morbidity and mortality. If patients experience symptomatic bradycardia, reduce the metoprolol dose. Initial difficulty with titration should not preclude later attempts to introduce therapy. Do not increase the dose until symptoms of worsening heart failure have been stabilized. If transient worsening of heart failure occurs, consider treating with increased doses of diuretics or lowering the dose or temporarily discontinuing metoprolol. Double the dose every 2 weeks as tolerated, up to the target dosage of 200 mg PO once daily. 12.5 or 25 mg PO once daily for 2 weeks, initially, in persons with NYHA class III or IV heart failure or NYHA class II heart failure, respectively.
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