Landiolol in perioperative and critical care: evidence, patient selection, and practical titration for targeted heart rate control: a narrative review

Figures

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  Fig. 1. Pharmacological profile and mechanism of action of landiolol. Landiolol is a highly β1-selective, ultra-short-acting adrenergic antagonist that reduces intracellular cyclic AMP (cAMP) following β1-receptor blockade, leading to a predominant negative chronotropic effect. Its rapid onset, short half-life, and high β1-selectivity allow precise and titratable heart rate control with limited systemic effects

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  Fig. 2. Proposed expert-based algorithm for landiolol use in critically ill patients with tachyarrhythmia. Assess hemodynamic stability in patients with new-onset supraventricular tachyarrhythmia. Unstable patients require urgent electrical cardioversion. In stable patients, consider rate control after bedside echocardiographic phenotyping and adequate resuscitation. Landiolol may be used in selected cases (e.g., LV dysfunction, borderline MAP, post-cardiac surgery, need for rapid titration) under continuous invasive monitoring (continuous arterial blood pressure monitoring, minimally invasive or invasive cardiac output/stroke volume monitoring). Discontinue if worsening of echocardiographic parameters, bradycardia, or increasing vasopressor requirements occur. If effective, consider gradual weaning or transition to longer-acting agents

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  Fig. 3. Proposed expert-based practical algorithm for landiolol use in septic shock patients. Expert-based practical algorithm for landiolol initiation, titration, and discontinuation in critically ill patients. LVEF, left ventricular ejection fraction; MAP, mean arterial pressure; SV, stroke volume