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

Landiolol enables rapid and titratable heart rate control in perioperative and critically ill patients. In supraventricular tachyarrhythmias and perioperative settings, available studies suggest effective rate control and acceptable hemodynamic tolerance. In sepsis and septic shock with persistent tachycardia, landiolol consistently lowers heart rate without increasing vasopressor requirements; however, randomized evidence does not demonstrate consistent benefits on major clinical outcomes, and current guidelines do not support its routine use. Emerging data on decatecholaminization strategies indicate that combining landiolol with non-adrenergic vasopressors may attenuate catecholamine-related toxicity and improve hemodynamic profiles. Experimental and perioperative studies also suggest potential anti-inflammatory effects through modulation of cytokine release. Overall, current evidence supports landiolol as a potentially useful option for acute heart rate control and selected cases of septic tachycardia. Nevertheless, given the heterogeneity of critically ill populations and the absence of clear outcome benefits in large randomized trials, its use should remain individualized and guided by careful hemodynamic monitoring, with particular attention to appropriate patient selection.