Early hemodynamic tolerance of landiolol in critically ill patients with supraventricular arrhythmia: a retrospective cohort study

Supraventricular arrhythmias are frequent in critically ill patients and landiolol, an ultra-short-acting, highly β1-selective adrenergic blocker, is increasingly used for their management. Its efficacy and dosing have been described, but its early hemodynamic tolerance at the bedside — when intolerance occurs, how it presents, and which patients are at risk — remains poorly characterized, particularly in vasopressor-dependent patients under-represented in existing cohorts. We aimed to describe the hemodynamic tolerance of landiolol and to identify bedside predictors of poor tolerance. We conducted a retrospective single-center study in patients admitted to the intensive care unit who received landiolol for supraventricular arrhythmia between January 2021 and February 2023. Hemodynamic variables, including pulse pressure, were recorded at baseline (H0) and at H1, H2, H4, H6 and H24. A hemodynamic adverse event was defined as a composite of mean arterial pressure below 64 mmHg, bradycardia below 50 bpm, or a more than 50% increase in vasopressor dose, counted only while landiolol was infused. Predictors of poor tolerance were identified by multivariable logistic regression. Among 133 patients (median age 68 years; SAPS II 51; sepsis 54.9%; vasopressors 49.6%), a hemodynamic adverse event occurred in 27 (20.3%), mostly within the first six hours. Events consisted of hypotension or vasopressor escalation; no patient developed bradycardia below 50 bpm. A lower diastolic pressure (adjusted OR 1.05 per 1-mmHg decrease, 95% CI 1.01–1.10) and vasopressor use at initiation (adjusted OR 3.00, 95% CI 1.14–7.91) were independently associated with poor tolerance. Heart rate control was achieved without deterioration of arterial pressure, pulse pressure, ventricular function, or tissue perfusion. Conversion to sinus rhythm was more frequent in new-onset than in pre-existing atrial fibrillation (54.4% vs. 27.9%; p = 0.004). In critically ill patients, hemodynamic intolerance to landiolol occurred in one-fifth of cases, arose early, and took the form of hypotension or increased vasopressor requirements rather than bradycardia. A low diastolic pressure and vasopressor dependence identified patients at risk, supporting cautious, individualized use with close monitoring during early titration.