Background – Rate control with beta adrenergic receptor blockers is the standard initial therapy in the management of tachyarrhythmias, especially atrial fibrillation. Its application in intensive care patients is often limited by hemodynamic instability, because of their negative inotropic effect and peripheral vasodilation. Landiolol, an ultra-short acting, β1-selective adrenoreceptor antagonist, which had been market-released only in Japan for several years, has become available in Europe in June 2017. Its short half-life provides highly flexible management of heart rate control in critically ill patients with little effect on blood pressure due to the high cardioselectivity.

Purpose We aimed to investigate Landiolol as a new tool for heart rate control in critically ill patients at our intensive care unit, in particular when standard therapy was failed or contraindicated.

Methods – We consecutively included critically ill patients with tachycardia and hypotension at our intensive care unit from June to December 2017. To be eligible to receive landiolol, patients had to present with detoriation of the hemodynamic status due to acute onset of tachycardia. Patients received continuous, intravenous landiolol therapy to reach rapid heart rate control. Heart rate, systolic, diastolic and mean arterial blood pressure (bp) were followed-up for two hours after treatment initiation.

Results – We identified ten critically ill patients at our intensive care unit with an acute onset of tachycardia and hypotension. Patients’ mean age was 66 (±15) years and they presented with moderately reduced left ventricular ejection fraction (LVEF, mean 40 (±12) %). Nine patients presented with new onset of atrial fibrillation, one patient had sinus tachycardia. 80% of patients with atrial fibrillation had already received a therapeutic approach with amiodarone and at least one failed external cardioversion. At the time of administration of landiolol patients presented with a mean heart rate of 163 (±17) beats per minute (bpm) and hypotension (mean: systolic bp 94 (±20) mmHg, diastolic bp 56 (±9) mmHg, mean bp 68 (±10) mmHg). At this time, seven patients received catecholamines.

One hour after initiation of a continuous, intravenous landiolol infusion a significant reduction of the heart rate had been achieved and it remained stable throughout the two hour follow-up. Patients with atrial fibrillation showed a decrease of 22 (±7) % of the initial heart, the patient with sinus tachycardia showed less reduction (9%). The evaluation of bp two hours after treatment initiation documented a stable hemodynamic situation (mean: systolic bp 97 (±12) mmHg, diastolic bp 59 (±6) mmHg, mean bp 71 (±10) mmHg). One septic patient with very high dose of catecholamine therapy at initiation of intravenous landiolol developed severe hypotension with necessity of cardio-pulmonary resuscitation shortly after administration.

Conclusion – In our case series, landiolol demonstrated rapid heart rate control without hemodynamic deterioration in the vast majority of critically ill patients on our intensive care unit.