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. Initially, 25 mg PO once daily in patients with NYHA class II heart failure or 12.5 mg PO once daily in patients with more severe heart failure.
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