Use of landiolol for acute heart rate management in critically ill cardiac patients: a retrospective single-center experience

Landiolol, an ultra-selective beta-1-blocker with rapid onset and short half-life, is increasingly used for heart rate control in critically ill patients. Existing studies primarily focus on on its use in septic shock and post-cardiac surgery, demonstrating effectiveness in managing heart rate and supporting hemodynamic stability. However, its safety and efficacy in acute cardiac conditions—including acute myocardial infarction (AMI), acute heart failure (AHF) and cardiogenic shock (CS)-remain less well-studied.

This study explores the use of landiolol in the Cardiac Intensive Care Unit (CICU) of an Italian tertiary center, offering new insights in high-risk non-septic cardiac patients.

This retrospective study evaluated patients admitted to our hospital from January 2023 to September 2024 who received landiolol for heart rate control. Inclusion criteria were age over 18 years and landiolol use for managing supraventricular or ventricular arrhythmias, while patients presenting with septic shock were excluded. The study assessed landiolol’s effects on heart rate, hemodynamic parameters, and perfusion indices, and evaluated safety based on treatment discontinuation due to side effects.

A total of 25 patients were enrolled in the study, with a median age of 64 years. Atrial fibrillation was the most commonly treated arrhythmia (52%), followed by ventricular arrhythmias (16%), atrial flutter (8%) and other supraventricular arrythmias (20%). Among these patients, 44% presented with CS, 20% with AHF, 8% with AMI, 4% with myocarditis and 24% with other acute cardiac conditions. The median dosage of landiolol was 10 mcg/kg/min, with a median treatment duration of 24 hours. Landiolol significantly reduced heart rate at both 2 hours (from 130 bpm [110-143] to 100 bpm [87-126], p=0.01) and at 24 hours (from 130 bpm [110-143] to 95 bpm [75-140], p=0.01), with 68% of patients achieving a reduction of at least 20 bpm in heart rate by the 24-hour mark. Hemodynamic parameters, including systolic blood pressure, central venous pressure and lactates, showed no significant adverse changes over the 24-hour period. Patients on inotropes or mechanical circulatory support, including intra-aortic balloon pump (28%) and extracorporeal membrane oxygenation (4%), tolerated landiolol without hemodynamic compromise. Landiolol was discontinued in only two patients due to side effects: hypotension in one case and bradycardia in the other.

Landiolol appears to be a safe and effective option for heart rate control in critically ill cardiac patients, including those with cardiogenic shock (CS), without compromising hemodynamic stability. These findings highlight landiolol’s potential as a valuable tool in high-risk CICU settings. Larger studies are needed to confirm these encouraging results and to further establish its role in managing complex cardiac cases.

Heart rate trends over time