Esmolol in the management of refractory ventricular fibrillation: a systematic review and meta-analysis

Background: Refractory ventricular fibrillation (rVF) presents a significant challenge in advanced cardiovascular life support (ACLS), with traditional antiarrhythmics showing limited success in improving long-term survival and neurological function. Esmolol, a beta-1 selective adrenergic receptor antagonist, might offer benefits due to its rapid onset and catecholamine-suppressing effects during cardiac arrest. Methods: This systematic review and meta-analysis (SRMA) evaluates the effectiveness of esmolol in improving the temporary return of spontaneous circulation (ROSC), sustained ROSC, survival to discharge, and survival to discharge with favorable neurological outcomes in rVF patients. This SRMA reviewed Medline (Ovid), Embase (Ovid), and Cochrane Central (Ovid) from their inception until October 2, 2025, for full-text clinical or observational studies assessing esmolol use alongside standard ACLS in adult rVF in both prehospital and in-hospital settings. Results: The risk of bias was independently assessed using the Newcastle-Ottawa Scale. Pooled risk ratios (RRs; 95% CI) are reported. Analyses in which I² >50% used a random-effects model; otherwise, a common-effect model was used. Four studies (n=273) are included. Esmolol was associated with an increased temporary ROSC (RR, 1.80; 95% CI, 1.09-2.98), and although the links were not statistically significant, esmolol trended toward a benefit in sustained ROSC (RR, 1.25; 95% CI, 0.28-5.66), survival to discharge (RR, 1.08; 95% CI, 0.57-2.03), and survival to discharge with favorable neurological outcomes (RR, 2.08; 95% CI, 0.83-5.24). Conclusions: Esmolol was associated with improved temporary ROSC in rVF. The sensitivity analysis suggests potential benefits for sustained ROSC and neurological survival, but more data are needed. Further research is needed to clarify its role.