Systolic-dicrotic notch pressure difference can identify tachycardic patients with septic shock at risk of cardiovascular decompensation following pharmacological heart rate reduction

Statins boost beneficial pleiotropic cardiovascular effects of cilostazol in angiotensin-II hypertensive rats

BACKGROUND AND AIMS

Hypertension is a major cause of cardiovascular (CVS) diseases. Statins exhibit a blood pressure-lowering effect independent of cholesterol. This study investigates whether combining statins with the phosphodiesterase-III inhibitor cilostazol enhances antihypertensive and cardioprotective effects.

METHODS

Hypertension was induced in rats via implanted mini-osmotic pumps releasing angiotensin II at 120 ng.kg-1.min-1 for 11 days. Hypertensive rats were treated with cilostazol (50 mg.kg-1.day-1), rosuvastatin (20 mg.kg-1.day-1), atorvastatin (50 mg.kg-1.day-1), or their combinations for seven days. Cardiovascular parameters, baroreflex sensitivity, histopathology, myocardial injury markers (creatine kinase-MB "CK-MB" and cardiac troponin I "cTnI"), and oxidative stress (catalase and malondialdehyde "MDA") were evaluated.

RESULTS

Cilostazol reduced systolic blood pressure, improved left ventricular (LV) function, and mitigated baroreflex dysfunction. Co-administration of atorvastatin enhanced these effects, with rosuvastatin showing greater improvements. The rosuvastatin/cilostazol combination significantly reduced myocardial injury, oxidative stress, and histopathological damage in the heart and aorta.

CONCLUSION

Statins, particularly rosuvastatin, enhanced cilostazol's antihypertensive and cardioprotective effects, highlighting the potential of this combination in managing hypertension and CVS diseases.

[Vasoactive agents in septic shock-individualized strategies]

Hemodynamic stabilization and preservation of organ perfusion are central elements in the management of septic shock. This is achieved by fluid resuscitation and by administration of vasoactive agents. Current guidelines recommend norepinephrine as the first-line vasoactive substance. In cases of high norepinephrine requirements the addition of nonadrenergic vasopressors is recommended. Furthermore, evidence suggests that early use of complementary vasoactive substances may provide additional benefits. Such a regimen, in terms of a broad-spectrum vasopressor approach, appears physiologically plausible. Post hoc analyses of studies investigating vasopressin or angiotensin II also suggest that specific subphenotypes may particularly benefit from individual vasoactive agents. Adjunctive therapy with hydrocortisone and fludrocortisone can improve vasopressor responsiveness and reduce mortality. In cases of cardiac dysfunction, a trial with dobutamine or a switch from norepinephrine to epinephrine is recommended. To enhance inodilator effects, milrinone or levosimendan may represent additional therapeutic options for certain patients. Although short-acting beta-blockers are not part of the standard treatment for septic shock, they may, in selected cases, contribute to hemodynamic improvement in patients with inadequately high sinus tachycardia or atrial tachyarrhythmias. Based on pathophysiological considerations and the currently available evidence, targeted use of specific vasoactive substances in defined subphenotypes may be justified. An initial broad-spectrum vasopressor strategy incorporating biomarkers such as renin and patient-specific characteristics followed by a focused de-escalation approach could represent a promising concept. However, the effectiveness of these strategies requires further investigation in randomized controlled trials.

Beta-blockade for the treatment of refractory hypoxaemia during venovenous extracorporeal membrane oxygenation: An in-silico study

IntroductionVenovenous extracorporeal membrane oxygenation (VV ECMO) is used for refractory hypoxemia, although despite this, in high cardiac output states, hypoxaemia may persist. The administration of beta-blockers has been suggested as an approach in this scenario, however the physiological consequences of this intervention are not clear.MethodsWe performed an in-silico study using a previously described mathematical model to evaluate the effect of beta-blockade on mixed venous and arterial saturations (S v ¯ O 2 , SaO2), in three different clinical scenarios and considered the potential effects of beta-blockers on, cardiac output, oxygen consumption and recirculation. Additionally we assessed the interaction of beta-blockade with haemoglobin concentration.ResultsIn scenario 1: simulating a patient with high cardiac output and partial lung shunt S v ¯ O 2 decreased from increased 53.5% to 44.7% despite SaO2 rising from 74.2% to 79.2%. In scenario 2 simulating a patient with high cardiac output and complete lung shunt S v ¯ O 2 remained unchanged at 52.2% and SaO2 rose from 71.9% to 85%. In scenario 3 a patient with normal cardiac output and high recirculation S v ¯ O 2 fell from 50.8% to 25.5% and also fell from 82.4% to to 78.3%. Across the remaining modelling examples the effect on S v ¯ O 2 varied but oxygen delivery was consistently reduced across all scenarios.ConclusionThe administration of beta-blockers for refractory hypoxemia during VV ECMO are unpredictable and may reduce oxygen delivery, although this will vary with patient and circuit features. This study does not support the use of beta-blockers for this indication.

Early β-Blocker Use and Clinical Outcomes in Acute Myocardial Injury: A Retrospective Cohort Study

BACKGROUND

Acute myocardial injury is defined by elevated cardiac troponin levels with a rising and/or falling pattern, and is associated with increased mortality risk compared to patients without myocardial injury. The role of β-blockers in patients with acute myocardial injury remains unclear.

METHODS

This multicenter, retrospective cohort study used data from the Tianjin Health and Medical Data Platform to assess the impact of early β-blocker use on 1-year all-cause mortality and major adverse cardiovascular events (MACE) in acute myocardial injury patients, employing a new user and target trial emulation design. Propensity score matching was applied, and Cox regression was used to calculate hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

After propensity score matching, a total of 25,966 participants were included: 8667 to the β-blocker group and 17,299 to the non-β-blocker group. A total of 4113 deaths (15.8%) and 5795 MACE (22.3%) occurred. Compared with nonusers, β-blocker was associated with the reduced risk of all-cause mortality (HR: 0.89, 95% CI: 0.83-0.95) and MACE (HR: 0.90, 95% CI: 0.85-0.95). In the subgroup analysis, β-blockers were associated with a significantly reduced risk of mortality in patients without stroke (HR 0.85, 95% CI: 0.78-0.93), while no significant association was observed in patients with stroke (HR 1.04, 95% CI: 0.93-1.16).

CONCLUSIONS

Early use of β-blockers is associated with the reduced risk of 1-year mortality in patients with acute myocardial injury. To more accurately assess the therapeutic effects, prospective trials are necessary, and these data provide key research directions for future trials.

Septic Cardiomyopathy: Difficult Definition, Challenging Diagnosis, Unclear Treatment

Sepsis is a systemic inflammatory response syndrome of suspected or confirmed infectious origin, which frequently culminates in multiorgan failure, including cardiac involvement. Septic cardiomyopathy (SCM) remains a poorly defined clinical entity, lacking a formal or consensus definition and representing a significant knowledge gap in critical care medicine. It is an often-underdiagnosed complication of sepsis. The only widely accepted aspect of its definition is that SCM is a transient myocardial dysfunction occurring in patients with sepsis, which cannot be attributed to ischemia or pre-existing cardiac disease. The pathogenesis of SCM appears to be multifactorial, involving inflammatory cytokines, overproduction of nitric oxide, mitochondrial dysfunction, calcium homeostasis dysregulation, autonomic imbalance, and myocardial edema. Diagnosis primarily relies on echocardiography, with advanced tools such as tissue Doppler imaging (TDI) and global longitudinal strain (GLS) providing greater sensitivity for detecting subclinical dysfunction and guiding therapeutic decisions. Traditional echocardiographic findings, such as left ventricular ejection fraction measured by 2D echocardiography, often reflect systemic vasoplegia rather than intrinsic myocardial dysfunction, complicating accurate diagnosis. Right ventricular (RV) dysfunction, identified as a critical component of SCM in many studies, has multifactorial pathophysiology. Factors including septic cardiomyopathy itself, mechanical ventilation, hypoxemia, and hypercapnia-particularly in cases complicated by acute respiratory distress syndrome (ARDS)-increase RV afterload and exacerbate RV dysfunction. The prognostic value of cardiac biomarkers, such as troponins and natriuretic peptides, remains uncertain, as these markers primarily reflect illness severity rather than being specific to SCM. Treatment focuses on the early recognition of sepsis, hemodynamic optimization, and etiological interventions, as no targeted therapies currently exist. Emerging therapies, such as levosimendan and VA-ECMO, show potential in severe SCM cases, though further validation is needed. The lack of standardized diagnostic criteria, combined with the heterogeneity of sepsis presentations, poses significant challenges to the effective management of SCM. Future research should focus on developing cluster-based classification systems for septic shock patients by integrating biomarkers, echocardiographic findings, and clinical parameters. These advancements could clarify the underlying pathophysiology and enable tailored therapeutic strategies to improve outcomes for SCM patients.

Effect of mean heart rate on 30-day mortality in older patients with sepsis: Data from the MIMIC-IV database

BACKGROUND

Sepsis is a critical condition with a significant risk of mortality. Advanced age is one factor in increasing mortality in intensive care.

OBJECTIVES

The aim of this study is to investigate the association between mean heart rate (MHR) and 30-day mortality among older patients with sepsis in the intensive care unit (ICU).

METHODS

All older patients (age 65 or older) with sepsis for first time in ICU admission in Medical Information Mart for Intensive Care-IV (MIMIC-IV) were included in this retrospective study. The effect of MHR within 24 h of ICU admission on 30-day mortality was assessed according to multivariable Cox regression models, restricted cubic splines and two-piecewise Cox regression models.

RESULTS

The total number of participants was 6598 (mean heart rate, 83.8 ± 14.3 bpm). A total of 1295 (19.6%) patients died within 30 days after ICU admission. MHR within 24 h of admission was associated with 30-day mortality (J-shaped association) in older patients with sepsis in the ICU, with an inflection point at about 74 bpm and a minimal risk observed at 73 to 82 bpm of MHR.

CONCLUSIONS

In this retrospective cohort study, there was a J-shaped association between MHR and 30-day mortality in older patients with sepsis admitted to the ICU and a minimal risk observed at 73 to 82 bpm of MHR. If further confirmed, this association may provide a theoretical basis for formulating the target strategy of heart rate therapy for these patients.

Comparison of the efficacy and safety of Landiolol and Esmolol in critically ill patients: a propensity score-matched study

BACKGROUND

Excessive tachycardia is associated with impaired hemodynamics and worse outcome in critically ill patients. Previous studies suggested beneficial effect of β-blockers administration in ICU patients, including those with septic shock. However, comparisons in ICU settings are lacking. Our study aims to compare Landiolol and Esmolol regarding heart rate control and hemodynamic variables in general ICU patients.

METHODS

This retrospective, observational study was conducted in a 56-bed ICU at a university hospital. A propensity score matching (PSM) was employed to balance baseline differences. Generalized estimating equations (GEE) were used to compare heart rate between two drugs. The primary outcome was heart rate control, while secondary outcomes included hemodynamic response, hospital length of stay (HLOS) and ICU length of stay (ICULOS).

RESULTS

From June 2016 to December 2022, 438 patients were included after PSM, (292 in the Esmolol group and 146 the in Landiolol group). Baseline heart rate was similar between groups (Landiolol:120.0 [110.2, 131.0] bpm vs. Esmolol:120.0 [111.0, 129.0] bpm, p = 0.925). During 72 h. of β-blocker infusion, Landiolol reduced heart rate by 4.7 (1.3, 8.1) bpm, more than Esmolol (p = 0.007), while preserving a comparable proportion of patients able to stabilize vasopressor doses within the first 24 h. (82.9 vs. 80.8%, respectively, p = 0.596). Norepinephrine doses and lactate levels were similar between groups over 72 h., while the Landiolol group exhibited notably higher minimal ScvO2 levels (72% [63%, 78%] vs 68% [55%, 73%], respectively, p = 0.006) and a lower maximal PCO2 gap compared to the Esmolol group (7.0 [6.0, 9.0] vs. 8.0 [6.0, 10.0] mmHg, respectively, p = 0.040). Patients in the Landiolol group were observed to experience shorter HLOS than patients in the Esmolol group (26.5 [13.0, 42.0] vs 30.0 [17.0, 47.2] days, respectively, p = 0.044) and ICULOS (4.9 [2.8, 10.0] vs.6.7 [3.4, 13.1] days, respectively, p = 0.011).

CONCLUSION

Landiolol provides superior heart rate control in critically ill patients with tachycardia compared to Esmolol, without increasing vasopressor requirements during the first 24 h. Findings from ScvO2 levels and PCO2 gap suggest that Landiolol may exert less impact on cardiac output than Esmolol. Further studies, incorporating comprehensive hemodynamic monitoring, are warranted to clarify the clinical implications of heart rate control with β-blockers in ICU patients with tachycardia.

Mortality in Patients With Sepsis Treated With Esmolol or Landiolol: A Systematic Review and Meta-Analysis of Randomized Controlled Trials With Trial Sequential Analysis

BACKGROUND

The latest meta-analysis indicated potential survival benefits from ultra-short-acting β-blockers in patients with sepsis with persistent tachycardia. However, subsequent multicenter randomized controlled trials (RCTs) have reported conflicting findings, prompting the need for an updated meta-analysis to incorporate these newly published RCTs.

RESEARCH QUESTION

Does the use of ultra-short-acting β-blockers (esmolol or landiolol) in patients with sepsis with persistent tachycardia improve mortality?

STUDY DESIGN AND METHODS

We conducted an updated systematic search through April 2, 2024, exploring the MEDLINE, Cochrane Central Register of Controlled Trials, and Embase databases for RCTs reporting mortality in adult patients with sepsis treated with esmolol or landiolol as compared with those treated with neither of these or receiving placebo and published in English. Meta-analyses were conducted with the random effects model. The primary outcome was mortality at the longest follow-up, with subgroup analysis separating single-center RCTS from large multicenter RCTs.

RESULTS

Eight RCTs (885 patients) were included in the primary analysis. Ultra-short-acting β-blockers did not improve mortality significantly at the longest follow-up (risk ratio, 0.84; 95% CI, 0.68-1.02; P = .08; I2 = 51%; very low certainty of the evidence) and 28-day mortality (risk ratio, 0.77; 95% CI, 0.59-1.00; P = .05; I2 = 62%). Subgroup analyses of mortality outcomes pointed toward different results between single-center and multicenter RCTs. Trial sequence analyses showed that both mortality outcomes were not robust. The sensitivity analyses suggested a significant reduction in mortality by adding RCTs published in non-English languages.

INTERPRETATION

In this updated meta-analysis, the use of esmolol or landiolol did not reduce mortality in patients with sepsis with persistent tachycardia. However, results were not robust and outcomes differed between single-center and multicenter RCTs. Moreover, sensitivity analyses showed the fragility of the primary outcome. Further studies regarding ultra-short-acting β-blockers with advanced cardiac monitoring or serial echocardiography are warranted.

TRIAL REGISTRY

International Prospective Register of Systematic Reviews; No.: CRD42024503570; URL: https://www.crd.york.ac.uk/prospero/.

Landiolol for heart rate control in patients with septic shock and persistent tachycardia. A multicenter randomized clinical trial (Landi-SEP)

PURPOSE

Excessive tachycardia in resuscitated septic shock patients can impair hemodynamics and worsen patient outcome. We investigated whether heart rate (HR) control can be achieved without increased vasopressor requirements using the titratable highly selective, ultra-short-acting β1-blocker landiolol.

METHODS

This randomized, open-label, controlled trial was conducted at 20 sites in 7 European countries from 2018 to 2022 and investigated the efficacy and safety of landiolol in adult patients with septic shock and persistent tachycardia. Patients were randomly assigned to receive either landiolol along with standard treatment (n = 99) or standard treatment alone (n = 101). The combined primary endpoint was HR response (i.e., HR within the range of 80-94 beats per minute) and its maintenance without increasing vasopressor requirements during the first 24 h after treatment start. Key secondary endpoints were 28-day mortality and adverse events.

RESULTS

Out of 196 included septic shock patients, 98 received standard treatment combined with landiolol and 98 standard treatment alone. A significantly larger proportion of patients met the combined primary endpoint in the landiolol group than in the control group (39.8% [39/98] vs. 23.5% [23/98]), with a between-group difference of 16.5% (95% confidence interval [CI]: 3.4-28.8%; p = 0.013). There were no statistically significant differences between study groups in tested secondary outcomes and adverse events.

CONCLUSION

The ultra-short-acting beta-blocker landiolol was effective in reducing and maintaining HR without increasing vasopressor requirements after 24 h in patients with septic shock and persistent tachycardia. There were no differences in adverse events and clinical outcomes such as 28-day mortality vs. standard of care. The results of this study, in the context of previous trials, do not support a treatment strategy of stringent HR reduction (< 95 bpm) in an unselected septic shock population with persistent tachycardia. Further investigations are needed to identify septic shock patient phenotypes that benefit clinically from HR control.

The role of pulse wave analysis indexes for critically ill patients: a narrative review

Objective.Arterial pulse wave analysis (PWA) is now established as a powerful tool to investigate the cardiovascular system, and several clinical studies have shown how PWA can provide valuable prognostic information over and beyond traditional cardiovascular risk factors. Typically these techniques are applied to chronic conditions, such as hypertension or aging, to monitor the slow structural changes of the vascular system which lead to important alterations of the arterial PW. However, their application to acute critical illness is not currently widespread, probably because of the high hemodynamic instability and acute dynamic alterations affecting the cardiovascular system of these patients.Approach.In this work we propose a review of the physiological and methodological basis of PWA, describing how it can be used to provide insights into arterial structure and function, cardiovascular biomechanical properties, and to derive information on wave propagation and reflection.Main results.The applicability of these techniques to acute critical illness, especially septic shock, is extensively discussed, highlighting the feasibility of their use in acute critical patients and their role in optimizing therapy administration and hemodynamic monitoring.Significance.The potential for the clinical use of these techniques lies in the ease of computation and availability of arterial blood pressure signals, as invasive arterial lines are commonly used in these patients. We hope that the concepts illustrated in the present review will soon be translated into clinical practice.

Effect of age and gender on ventricular-arterial coupling estimated using a non-invasive technique

BACKGROUND

Left ventricular-arterial coupling is assessed as the ratio of left ventricular end-systolic elastance (Ees) to arterial elastance (Ea). Previous studies have introduced non-invasive estimations of Ees/Ea. It requires only four variables, namely pre-ejection period, ejection time, end-systolic pressure and diastolic pressure. The aims of the present study were to clarify the reference values of Ees/Ea estimated using the noninvasive technique, and to investigate the effects of age and gender on Ees/Ea in healthy subjects.

METHODS

This retrospective study utilized data from healthy, 30-79-year-old subjects. We recorded electrocardiogram, phonocardiogram, and brachial arterial pulse waves simultaneously using the vascular screening system, and used the observed variables to calculate Ees/Ea. We separated subjects into five groups according to their age and compared Ees/Ea among the different age groups.

RESULTS

The study included 2114 males and 2292 females. Ees/Ea ranged from 1.87 to 2.04 in males, and 1.98 to 2.32 in females. We observed no age-related differences in Ees/Ea in males (p = 0.10), and significant differences in females (p < 0.001). Ees/Ea in males was not different compared to those in females in 60-69-year-old group (p = 0.92). Whereas Ees/Ea was higher in females compared to those in males in the other age groups. The differences between medians of Ees/Ea in males and those in females were 0.45 (p < 0.001), 0.24 (p < 0.001), 0.13 (p = 0.01), and 0.13 (p = 0.03) in 30-39, 40-49, 50-59, and 70-79-year-old age groups, respectively.

CONCLUSIONS

We clarified the reference values of Ees/Ea in healthy subjects. The effect of age on Ees/Ea is different in males and females, although Ees/Ea is maintained within a relatively narrow range in all subjects.

Prevalence and prognosis of hyperdynamic left ventricular systolic function in septic patients: a systematic review and meta-analysis

PURPOSE

The prevalence of hyperdynamic left ventricular (LV) systolic function in septic patients and its impact on mortality remain controversial. In this systematic review and meta-analysis, we investigated the prevalence and association of hyperdynamic LV systolic function with mortality in patients with sepsis.

METHODS

We searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. Primary outcomes were the prevalence of hyperdynamic LV systolic function in adult septic patients and the associated short-term mortality as compared to normal LV systolic function. Hyperdynamic LV systolic function was defined using LV ejection fraction (LVEF) of 70% as cutoff. Secondary outcomes were heart rate, LV end-diastolic diameter (LVEDD), and E/e' ratio.

RESULTS

Four studies were included, and the pooled prevalence of hyperdynamic LV systolic function was 18.2% ([95% confidence interval (CI) 12.5, 25.8]; I2 = 7.0%, P < 0.0001). Hyperdynamic LV systolic function was associated with higher mortality: odds ratio of 2.37 [95%CI 1.47, 3.80]; I2 = 79%, P < 0.01. No difference was found in E/e' (P = 0.43) between normal and hyperdynamic LV systolic function, while higher values of heart rate (mean difference: 6.14 beats/min [95%CI 3.59, 8.69]; I2 = 51%, P < 0.0001) and LVEDD (mean difference: - 0.21 cm [95%CI - 0.33, - 0.09]; I2 = 73%, P < 0.001) were detected in patients with hyperdynamic LV systolic function.

CONCLUSION

The prevalence of hyperdynamic LV systolic function is not negligible in septic patients. Such a finding is associated with significantly higher short-term mortality as compared to normal LV systolic function.

Diastology in the intensive care unit: Challenges for the assessment and future directions

Myocardial dysfunction is common in patients admitted to the intensive care unit (ICU). Septic disease frequently results in cardiac dysfunction, and sepsis represents the most common cause of admission and death in the ICU. The association between left ventricular (LV) systolic dysfunction and mortality is not clear for critically ill patients. Conversely, LV diastolic dysfunction (DD) seems increasingly recognized as a factor associated with poor outcomes, not only in sepsis but also more generally in critically ill patients. Despite recent attempts to simplify the diagnosis and grading of DD, this remains relatively complex, with the need to use several echocardiographic parameters. Furthermore, the current guidelines have several intrinsic limitations when applied to the ICU setting. In this manuscript, we discuss the challenges in DD classification when applied to critically ill patients, the importance of left atrial pressure estimates for the management of patients in ICU, and whether the study of cardiac dysfunction spectrum during critical illness may benefit from the integration of left ventricular and left atrial strain data to improve diagnostic accuracy and implications for the treatment and prognosis.

The "CHEOPS" bundle for the management of Left Ventricular Diastolic Dysfunction in critically ill patients: an experts' opinion

The impact of left ventricular (LV) diastolic dysfunction (DD) on the outcome of patients with heart failure was established over three decades ago. Nevertheless, the relevance of LVDD for critically ill patients admitted to the intensive care unit has seen growing interest recently, and LVDD is associated with poor prognosis. Whilst an assessment of LV diastolic function is desirable in critically ill patients, treatment options for LVDD are very limited, and pharmacological possibilities to rapidly optimize diastolic function have not been found yet. Hence, a proactive approach might have a substantial role in improving the outcomes of these patients. Recalling historical Egyptian parallelism suggesting that Doppler echocardiography has been the "Rosetta stone" to decipher the study of LV diastolic function, we developed a potentially useful acronym for physicians at the bedside to optimize the management of critically ill patients with LVDD with the application of the bundle. We summarized the bundle under the acronym of the famous ancient Egyptian pharaoh CHEOPS: Chest Ultrasound, combining information from echocardiography and lung ultrasound; HEmodynamics assessment, with careful evaluation of heart rate and rhythm, as well as afterload and vasoactive drugs; OPtimization of mechanical ventilation and pulmonary circulation, considering the effects of positive end-expiratory pressure on both right and left heart function; Stabilization, with cautious fluid administration and prompt fluid removal whenever judged safe and valuable. Notably, the CHEOPS bundle represents experts' opinion and are not targeted at the initial resuscitation phase but rather for the optimization and subsequent period of critical illness.

Landiolol and Organ Failure in Patients With Septic Shock: The STRESS-L Randomized Clinical Trial

Importance

Patients with septic shock undergo adrenergic stress, which affects cardiac, immune, inflammatory, and metabolic pathways. β-Blockade may attenuate the adverse effects of catecholamine exposure and has been associated with reduced mortality.

Objectives

To assess the efficacy and safety of landiolol in patients with tachycardia and established septic shock requiring prolonged (>24 hours) vasopressor support.

Design, Setting, and Participants

An open-label, multicenter, randomized trial involving 126 adults (≥18 years) with tachycardia (heart rate ≥95/min) and established septic shock treated for at least 24 hours with continuous norepinephrine (≥0.1 μg/kg/min) in 40 UK National Health Service intensive care units. The trial ran from April 2018 to December 2021, with early termination in December 2021 due to a signal of possible harm.

Intervention

Sixty-three patients were randomized to receive standard care and 63 to receive landiolol infusion.

Main Outcomes and Measures

The primary outcome was the mean Sequential Organ Failure Assessment (SOFA) score from randomization through 14 days. Secondary outcomes included mortality at days 28 and 90 and the number of adverse events in each group.

Results

The trial was stopped prematurely on the advice of the independent data monitoring committee because it was unlikely to demonstrate benefit and because of possible harm. Of a planned 340 participants, 126 (37%) were enrolled (mean age, 55.6 years [95% CI, 52.7 to 58.5 years]; 58.7% male). The mean (SD) SOFA score in the landiolol group was 8.8 (3.9) compared with 8.1 (3.2) in the standard care group (mean difference [MD], 0.75 [95% CI, -0.49 to 2.0]; P = .24). Mortality at day 28 after randomization in the landiolol group was 37.1% (23 of 62) and 25.4% (16 of 63) in the standard care group (absolute difference, 11.7% [95% CI, -4.4% to 27.8%]; P = .16). Mortality at day 90 after randomization was 43.5% (27 of 62) in the landiolol group and 28.6% (18 of 63) in the standard care group (absolute difference, 15% [95% CI, -1.7% to 31.6%]; P = .08). There were no differences in the number of patients having at least one adverse event.

Conclusion and Relevance

Among patients with septic shock with tachycardia and treated with norepinephrine for more than 24 hours, an infusion of landiolol did not reduce organ failure measured by the SOFA score over 14 days from randomization. These results do not support the use of landiolol for managing tachycardia among patients treated with norepinephrine for established septic shock.

Trial Registration

EU Clinical Trials Register Eudra CT: 2017-001785-14; isrctn.org Identifier: ISRCTN12600919.

The role of beta-blocker drugs in critically ill patients: a SIAARTI expert consensus statement

BACKGROUND

The role of β-blockers in the critically ill has been studied, and data on the protective effects of these drugs on critically ill patients have been repeatedly reported in the literature over the last two decades. However, consensus and guidelines by scientific societies on the use of β-blockers in critically ill patients are still lacking. The purpose of this document is to support the clinical decision-making process regarding the use of β-blockers in critically ill patients. The recipients of this document are physicians, nurses, healthcare personnel, and other professionals involved in the patient's care process.

METHODS

The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) selected a panel of experts and asked them to define key aspects underlying the use of β-blockers in critically ill adult patients. The methodology followed by the experts during this process was in line with principles of modified Delphi and RAND-UCLA methods. The experts developed statements and supportive rationales in the form of informative text. The overall list of statements was subjected to blind votes for consensus.

RESULTS

The literature search suggests that adrenergic stress and increased heart rate in critically ill patients are associated with organ dysfunction and increased mortality. Heart rate control thus seems to be critical in the management of the critically ill patient, requiring careful clinical evaluation aimed at both the differential diagnosis to treat secondary tachycardia and the treatment of rhythm disturbance. In addition, the use of β-blockers for the treatment of persistent tachycardia may be considered in patients with septic shock once hypovolemia has been ruled out. Intravenous application should be the preferred route of administration.

CONCLUSION

β-blockers protective effects in critically ill patients have been repeatedly reported in the literature. Their use in the acute treatment of increased heart rate requires understanding of the pathophysiology and careful differential diagnosis, as all causes of tachycardia should be ruled out and addressed first.

Ventriculo-arterial (un)coupling in septic shock: Impact of current and upcoming hemodynamic drugs

Sepsis is an archetype of distributive shock and combines different levels of alterations in preload, afterload, and often cardiac contractility. The use of hemodynamic drugs has evolved over the past few years, along with the invasive and non-invasive tools used to measure these components in real time. However, none of them is impeccable, which is why the mortality of septic shock remains too high. The concept of ventriculo-arterial coupling (VAC) allows for the integration of these three fundamental macroscopic hemodynamic components. In this mini review, we discuss the knowledge, tools, and limitations of VAC measurement, along with the evidence supporting ventriculo-arterial uncoupling in septic shock. Finally, the impact of recommended hemodynamic drugs and molecules on VAC is detailed.

Distinct morphologies of arterial waveforms reveal preload-, contractility-, and afterload-deficient hemodynamic instability: An in silico simulation study

Hemodynamic instability is frequently present in critically ill patients, primarily caused by a decreased preload, contractility, and/or afterload. We hypothesized that peripheral arterial blood pressure waveforms allow to differentiate between these underlying causes. In this in-silico experimental study, a computational cardiovascular model was used to simulate hemodynamic instability by decreasing blood volume, left ventricular contractility or systemic vascular resistance, and additionally adaptive and compensatory mechanisms. From the arterial pressure waveforms, 45 features describing the morphology were discerned and a sensitivity analysis and principal component analysis were performed, to quantitatively investigate their discriminative power. During hemodynamic instability, the arterial waveform morphology changed distinctively, for example, the slope of the systolic upstroke having a sensitivity of 2.02 for reduced preload, 0.80 for reduced contractility, and -0.02 for reduced afterload. It was possible to differentiate between the three underlying causes based on the derived features, as demonstrated by the first two principal components explaining 99% of the variance in waveforms. The features with a high correlation coefficient (>0.25) to these principal components are describing the systolic up- and downstroke, and the anacrotic and dicrotic notches of the waveforms. In this study, characteristic peripheral arterial waveform morphologies were identified that allow differentiation between deficits in preload, contractility, and afterload causing hemodynamic instability. These findings are confined to an in silico simulation and warrant further experimental and clinical research in order to prove clinical usability in daily practice.

Beta-blockers in septic shock: What is new?

The use of beta(β)-blockers during septic shock aimed at countering peripheral adrenergic stress may be justified by the early reduction in deleterious effects resulting from sympathetic overactivation, and could improve the prognosis of patients in septic shock. Animal studies have demonstrated either a maintenance or increase in cardiac output (CO) despite the decrease in heart rate (HR) associated with improved myocardial performance. The mechanism by which β-blockers alter hemodynamics in septic shock is debated; however, preclinical and clinical data show that β-blockers are safe when started at a low dose. Recent publications (2019-2021) on adrenergic β1 receptor antagonists used in septic shock indicate that esmolol and landiolol should not be used in the early phase. While there is no optimal timing for their administration, a minimum of 12 h after the initiation of vasopressor therapy in stabilized euvolemic patients is a reasonable option. Patients should have a normal cardiac function, although a slight depression is compatible with landiolol use under hemodynamic monitoring. Slow titration in patients who remain tachycardic is preferable to rapid titration. When used to decrease HR, landiolol is also effective in reducing the incidence of new arrhythmias. Results of a well-performed and well-powered randomized controlled trial (RCT) demonstrating a positive effect on survival - or at least on hard surrogates such as the incidence/duration of organ failure - are pending.

Septic cardiomyopathy: Diagnosis and management

There is an extensive body of literature focused on sepsis-induced myocardial dysfunction, but results are conflicting and no objective definition of septic cardiomyopathy (SCM) has been established. SCM may be defined as a sepsis-associated acute syndrome of non-ischemic cardiac dysfunction with systolic and/or diastolic left ventricular (LV) dysfunction and/or right ventricular dysfunction. Physicians should consider this diagnosis in patients with sepsis-associated organ dysfunction, and particularly in cases of septic shock that require vasopressors. Echocardiography is currently the gold standard for diagnosis of SCM. Left ventricular ejection fraction is the most common parameter used to describe LV function in the literature, but its dependence on loading conditions, particularly afterload, limits its use as a measure of intrinsic myocardial contractility. Therefore, repeated echocardiography evaluation is mandatory. Evaluation of global longitudinal strain (GLS) may be more sensitive and specific for SCM than LV ejection fraction (LVEF). Standard management includes etiological treatment, adapted fluid resuscitation, use of vasopressors, and monitoring. Use of inotropes remains uncertain, and heart rate control could be an option in some patients.

Current practice and evolving concepts in septic shock resuscitation

Clinical and pathophysiological understanding of septic shock has progressed exponentially in the previous decades, translating into a steady decrease in septic shock-related morbidity and mortality. Even though large randomized, controlled trials have addressed fundamental aspects of septic shock resuscitation, many questions still exist. In this review, we will describe the current standards of septic shock resuscitation, but the emphasis will be placed on evolving concepts in different domains such as clinical resuscitation targets, adequate use of fluids and vasoactive drugs, refractory shock, and the use of extracorporeal therapies. Multiple research opportunities remain open, and collaborative endeavors should be performed to fill in these gaps.

Self-Nanoemulsifying Drug Delivery System Loaded with Psiadia punctulata Major Metabolites for Hypertensive Emergencies: Effect on Hemodynamics and Cardiac Conductance

Vasodilators are an important class of antihypertensive agents. However, they have limited clinical use due to the reflex tachycardia associated with their use which masks most of its antihypertensive effect and raises cardiac risk. Chemical investigation of Psiadia punctulata afforded five major methoxylated flavonoids (1–5) three of which (1, 4, and 5) showed vasodilator activity. Linoleic acid-based self-nanoemulsifying drug delivery system (SNEDDS) was utilized to develop intravenous (IV) formulations that contain compounds 1, 4, or 5. The antihypertensive effect of the prepared SNEDDS formulations, loaded with each of the vasodilator compounds, was tested in the angiotensin-induced rat model of hypertension. Rats were subjected to real-time recording of blood hemodynamics and surface Electrocardiogram (ECG) while the pharmaceutical formulations were individually slowly injected in cumulative doses. Among the tested formulations, only that contains umuhengerin (1) and 5,3′-dihydroxy-6,7,4′,5′-tetramethoxyflavone (5) showed potent antihypertensive effects. Low IV doses, from the prepared SNEDDS, containing either compound 1 or 5 showed a marked reduction in the elevated systolic blood pressure by 10 mmHg at 12 μg/kg and by more than 20 mmHg at 36 μg/kg. The developed SNEDDS formulation containing either compound 1 or 5 significantly reduced the elevated diastolic, pulse pressure, dicrotic notch pressure, and the systolic–dicrotic notch pressure difference. Moreover, both formulations decreased the ejection duration and increased the non-ejection duration while they did not affect the time to peak. Both formulations did not affect the AV conduction as appear from the lack of effect on p duration and PR intervals. Similarly, they did not affect the ventricular repolarization as no effect on QTc or JT interval. Both formulations decreased the R wave amplitude but increased the T wave amplitude. In conclusion, the careful selection of linoleic acid for the development of SNEDDS formulation rescues the vasodilating effect of P. punctulata compounds from being masked by the reflex tachycardia that is commonly associated with the decrease in peripheral resistance by most vasodilators. The prepared SNEDDS formulation could be suggested as an effective medication in the treatment of hypertensive emergencies, after clinical evaluation.

Adjunctive treatments for the management of septic shock - a narrative review of the current evidence

Septic shock is a leading cause of death and morbidity worldwide. The cornerstones of management include prompt identification of sepsis, early initiation of antibiotic therapy, adequate fluid resuscitation and organ support. Over the past two decades, there have been considerable improvements in our understanding of the pathophysiology of sepsis and the host response, including regulation of inflammation, endothelial disruption and impaired immunity. This has offered opportunities for innovative adjunctive treatments such as vitamin C, corticosteroids and beta-blockers. Some of these approaches have shown promising results in early phase trials in humans, while others, such as corticosteroids, have been tested in large, international, multicentre randomised controlled trials. Contemporary guidelines make a weak recommendation for the use of corticosteroids to reduce mortality in sepsis and septic shock. Vitamin C, despite showing initial promise in observational studies, has so far not been shown to be clinically effective in randomised trials. Beta-blocker therapy may have beneficial cardiac and non-cardiac effects in septic shock, but there is currently insufficient evidence to recommend their use for this condition. The results of ongoing randomised trials are awaited. Crucial to reducing heterogeneity in the trials of new sepsis treatments will be the concept of enrichment, which refers to the purposive selection of patients with clinical and biological characteristics that are likely to be responsive to the intervention being tested.

Effect of Ultrashort-Acting β-Blockers on Mortality in Patients With Sepsis With Persistent Tachycardia Despite Initial Resuscitation: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Historically, β-blockers have been considered to be relatively contraindicated for septic shock because they may cause cardiac suppression. On the other hand, there is an increasing interest in the use of β-blockers for treating patients with sepsis with persistent tachycardia despite initial resuscitation.

RESEARCH QUESTION

Do ultrashort-acting β-blockers such as esmolol and landiolol improve mortality in patients with sepsis with persistent tachycardia despite initial resuscitation?

STUDY DESIGN AND METHODS

This was a systematic review and meta-analysis. We searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase for randomized controlled trials (RCTs) that compared the mortality of patients with sepsis and septic shock treated with esmolol or landiolol. We updated our search on April 20, 2020. Two independent reviewers assessed whether titles and abstracts met the following eligibility criteria: (1) RCT, (2) patients with sepsis and septic shock ≥ 18 years of age, and (3) treatment with either esmolol/landiolol or placebo/no interventions. Two authors independently extracted selected patient and study characteristics and outcomes. The results of all analyses are presented using random effect models.

RESULTS

Seven RCTs with a pooled sample size of 613 patients were included. Of these, six RCTs with 572 patients reported 28-day mortality. Esmolol or landiolol use in patients with sepsis and septic shock was significantly associated with lower 28-day mortality (risk ratio, 0.68; 95% CI, 0.54-0.85; P < .001). Unimportant heterogeneity was observed (I² = 31%). The absolute risk reduction and number of patients to be treated to prevent one death were 18.2% and 5.5, respectively.

INTERPRETATION

The use of ultrashort-acting β-blockers such as esmolol and landiolol in patients with sepsis with persistent tachycardia despite initial resuscitation was associated with significantly lower 28-day mortality.

TRIAL REGISTRY

UMIN Clinical Trials Registry; No.: UMIN000040174; URL: https://www.umin.ac.jp/ctr/index.htm.

Hemodynamic and anti-inflammatory effects of early esmolol use in hyperkinetic septic shock: a pilot study

Background

Several studies have shown that heart rate control with selective beta-1 blockers in septic shock is safe. In these trials, esmolol was administered 24 h after onset of septic shock in patients who remained tachycardic. While an earlier use of beta-blockers might be beneficial, such use remains challenging due to the difficulty in distinguishing between compensatory and non-compensatory tachycardia. Therefore, the Esmosepsis study was designed to study the effects of esmolol aimed at reducing the heart rate by 20% after the initial resuscitation process in hyperkinetic septic shock patients on (1) cardiac index and (2) systemic and regional hemodynamics as well as inflammatory patterns.

Methods

Nine consecutive stabilized tachycardic hyperkinetic septic shock patients treated with norepinephrine for a minimum of 6 h were included. Esmolol was infused during 6 h in order to decrease the heart rate by 20%. The following data were recorded at hours H0 (before esmolol administration), H1–H6 (esmolol administration) and 1 h after esmolol cessation (H7): systolic arterial pressure, diastolic arterial pressure, mean arterial pressure, central venous pressure, heart rate, PICCO transpulmonary thermodilution, sublingual and musculo-cutaneous microcirculation, indocyanine green clearance and echocardiographic parameters, diuresis, lactate, and arterial and venous blood gases.

Results

Esmolol was infused 9 (6.4–11.6) hours after norepinephrine introduction. Esmolol was ceased early in 3 out of 9 patients due to a marked increase in norepinephrine requirement associated with a picture of persistent cardiac failure at the lowest esmolol dose. For the global group, during esmolol infusion, norepinephrine infusion increased from 0.49 (0.34–0.83) to 0.78 (0.3–1.11) µg/min/kg. The use of esmolol was associated with a significant decrease in heart rate from 115 (110–125) to 100 (92–103) beats/min and a decrease in cardiac index from 4.2 (3.1–4.4) to 2.9 (2.5–3.7) l/min/m⁻². Indexed stroke volume remained unchanged. Cardiac function index and global ejection fraction also markedly decreased. Using echocardiography, systolic, diastolic as well as left and right ventricular function parameters worsened. After esmolol cessation, all parameters returned to baseline values. Lactate and microcirculatory parameters did not change while the majority of pro-inflammatory proteins decreased in all patients.

Conclusion

In the very early phase of septic shock, heart rate reduction using fast esmolol titration is associated with an increased risk of hypotension and decreased cardiac index despite maintained adequate tissue perfusion (NCT02068287).