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Hypotension and off-label use: case report. A 49-year-old man developed hypotension during treatment with metoprolol for heart failure secondary to acute inferior myocardial infarction. Additionally, he received off-label therapy with ivabradine for heart failure secondary to acute inferior myocardial infarction. The man, who had been diagnosed with acute inferior myocardial infarction in February 2016, presented to a hospital due to continued palpitations and heart failure despite treatment with aspirin, clopidogrel, atorvastatin, enoxaparin sodium [enoxaparin] and isosorbide mononitrate. He had been receiving oral metoprolol 25mg twice daily for several years with poor control of his BP. He had received aspirin, clopidogrel, atorvastatin, enoxaparin sodium [enoxaparin] and isosorbide mononitrate in an another hospital; however, he continued to have chest pain and palpitations after these treatments. On presentation, he was transferred the coronary care unit where he again received aspirin, clopidogrel and atorvastatin, but at the highest dosages permitted by his clinical condition. As he continued to be ill and continued to experience chest pain for 1 week, coronary angiography and percutaneous coronary intervention were performed. In the evening of the first day, he experienced heart failure. His blood pressure was 87–98/60–70mm Hg, HR was 90–120 bpm, and NT-proBNP was 2286 pg/mL. He was given dopamine to maintain BP. Simultaneously, he received lyophilised recombinant human brain natriuretic peptide (Irh-BNP) to antagonise the renin-angiotensin system (RAS) and diuretics (furosemide and spironolactone) to reduce heart load, which may improve his heart function. The dose of metoprolol was reduced to 12.5mg twice daily because of hypotension [duration of treatment to reaction onset stated]. After several days, the symptoms of heart failure disappeared. After discharge, he took metoprolol regularly. After one month, he returned with complaints of dyspnoea and palpitations; his BP was 115/88mm Hg and his HR was 110 bpm. The dose of metoprolol was increased to 25mg two times a day, but he continued to have palpitations. Further dose titration of metroprol was deferred due to his BP fluctuating between 100–105/60–70mm Hg. His HR remained high (100–130 bpm). It was concluded that the high HR was the driving force of the palpitations. The man received off-label therapy with ivabradine [route not stated] 5mg twice daily to alleviate the symptoms related to his HR and palpitations without affecting his BP so as to promote the recovery of heart function. Subsequently, a gradual reduction in his HR and a gradual increase in his BP was noted. After approximately 1 week of clinical observation, he was discharged. After one week, his HR was 96 bpm, and BP was 98–116/60–80mm Hg. The dose of ivabradine was then increased to 7.5mg twice daily. Additionally, he received candesartan-cilexetil [candesartan]. After one month, his HR was 84 bpm and BP was 100–118/65–85mm Hg. Thereafter, the dose of metoprolol was increased to 37