Targeted Heart Rate Control with Landiolol in Hemodynamically Unstable, Non-Surgical Intensive Care Unit Patients: A...

Background and Objectives: Atrial fibrillation (AF) in critically ill patients (CIP) is associated with worse outcomes and increased mortality in the intensive care unit (ICU). Rhythm control strategies are often unfeasible due to underlying comorbidities, making rate control the preferred initial approach. However, conventional beta-blockers may worsen hemodynamics through negative inotropic effects and peripheral vasodilation. Landiolol, an ultra-short-acting adrenoreceptor antagonist, may offer an alternative due to its high β₁-cardioselectivity and minimal blood pressure (BP) impact. This study evaluated the efficacy and feasibility of landiolol in hemodynamically unstable CIP with tachyarrhythmia, used as add-on therapy after failure of standard treatments. Materials and Methods: Ten CIP, admitted for non-postoperative reasons, were prospectively enrolled for landiolol treatment (L-group) in the ICU of Ulm University Heart Center between July and December 2017. The control group contained 41 patients who had received standard therapy without landiolol (NL-group). The primary composite endpoint was defined as heart rate (HR) reduction while maintaining mean arterial pressure (MAP) above 65 mmHg. Results: The most frequent reason for ICU admission was hemodynamic instability related to tachyarrhythmia in patients with cardiogenic or septic shock. At therapy initiation, all patients exhibited a compromised hemodynamic status, with a median MAP of 68.0 (IQR 60.0-80.0) mmHg and a median HR of 160.0 (IQR 144.0-176.0) bpm. After a three-hour observation period, no significant differences in BP values were observed between the groups. The primary composite endpoint was achieved at comparable rates in both groups (p = 0.525). However, patients in the L-group achieved a greater reduction in HR compared to those in the NL-group (25.3% vs. 21.9%, p < 0.001). Conclusions: Landiolol achieved more effective HR control than standard therapy without adversely affecting BP stability. These findings suggest that landiolol may be a feasible and effective option for HR control in ICU CIP.