Evaluating the Therapeutic Efficacy and Safety of Landiolol Hydrochloride for Management of Arrhythmia in Critical Settings: Review of the Literature

An Overview of the Pharmacokinetics and Pharmacodynamics of Landiolol (an Ultra-Short Acting β1 Selective Antagonist) in Atrial Fibrillation

Landiolol is an ultra-short-acting, selective β1-adrenergic receptor blocker that was originally approved in Japan for the treatment of intraoperative tachyarrhythmias. It has gained attention for its use in the management of tachyarrhythmias and perioperative tachycardia, especially atrial fibrillation for both cardiac and non-cardiac surgeries. It can be the ideal agent for heart rate control due to its high β1-selectivity, potent negative chronotropic effect, a limited negative inotropic potential, and an ultrashort elimination half-life (around 4 min); moreover, it may have a potential therapeutic effects for sepsis and pediatric patients. Landiolol seems to be superior to other short-acting and selective beta-blockers such as esmolol. This review aims to provide a comprehensive overview of landiolol, a new ultra-short-acting β1 selective antagonist, including its pharmacology, clinical applications, efficacy, safety profile, and future directions in research and clinical data.

Diagnosis and Treatment of New-Onset Perioperative Atrial Fibrillation

This article reviews medical and surgical risk factors for developing atrial fibrillation (AF), the most common sustained dysrhythmia in the United States. Evidence for assessment and management of patients with AF, including AF newly identified in the preoperative clinic, immediately preoperatively, intraoperatively, and unstable AF, is presented. A stepwise approach to guide anesthetic decision-making in the assessment of newly identified preoperative AF is proposed. Anesthetic considerations, including the potential impacts of anesthetic and vasopressor selection, and current evidence related to rate control and rhythm control via pharmacologic or electrical cardioversion as well as anticoagulation strategies are discussed.

Optimal use of intravenous landiolol in acute cardiac care

INTRODUCTION

B-blockers are regarded as beneficial pharmacologic agents in cardiac care, but their role in the acute setting remains ambiguous. Increasing evidence supports the important role of landiolol in critical care, a highly cardioselective intravenous b-blocker with rapid onset of action and short elimination time. Among its most valuable properties, which may aid to overcome special reservations related to b-blocker therapy in the acute setting, landiolol has a potent negative chronotropic effect while at the same time it exhibits a mild negative inotropic effect.

AREAS COVERED

This expert opinion review aims to present basic pharmacologic aspects of landiolol and provide current clinical research focused on its efficacy and safety.

EXPERT OPINION

Landiolol is a valuable and safe pharmacologic agent in acute cardiac care. Japanese and European guidelines have incorporated its use for the management of atrial tachyarrhythmia in patients with cardiac dysfunction. Although emerging clinical trials have experimented its use in patients with sustained ventricular tachycardia/fibrillation, acute myocardial infarction undergoing primary percutaneous intervention and in patients with septic cardiomyopathy, more studies are needed in order to establish its value in such cardiac conditions.

Hemodynamic and Rhythmologic Effects of Push-Dose Landiolol in Critical Care-A Retrospective Cross-Sectional Study

BACKGROUND

The highly β1-selective beta-blocker Landiolol is known to facilitate efficient and safe rate control in non-compensatory tachycardia or dysrhythmia when administered continuously. However, efficacy and safety data of the also-available bolus formulation in critically ill patients are scarce.

METHODS

We conducted a retrospective cross-sectional study on a real-life cohort of critical care patients, who had been treated with push-dose Landiolol due to sudden-onset non-compensatory supraventricular tachycardia. Continuous hemodynamic data had been acquired via invasive blood pressure monitoring.

RESULTS

Thirty patients and 49 bolus applications were analyzed. Successful heart rate control was accomplished in 20 (41%) cases, rhythm control was achieved in 13 (27%) episodes, and 16 (33%) applications showed no effect. Overall, the heart rate was significantly lower (145 (130-150) vs. 105 (100-125) bpm, p < 0.001) in a 90 min post-application observational period in all subgroups. The median changes in blood pressure after the bolus application did not reach clinical significance. Compared with the ventilation settings before the bolus application, the respiratory settings including the required FiO2 after the bolus application did not differ significantly. No serious adverse events were seen.

CONCLUSIONS

Push-dose Landiolol was safe and effective in critically ill ICU patients. No clinically relevant impact on blood pressure was noted.

Effect of landiolol in patients with tachyarrhythmias and acute decompensated heart failure (ADHF): a case series

Tachycardia and rapid tachyarrhythmias are common in acute clinical settings and may hasten the deterioration of haemodynamics in patients with acute decompensated heart failure (ADHF), treated with inotropes. The concomitant use of a short‐acting β1‐selective beta‐blocker, such as landiolol, could rapidly and safely restore an adequate heart rate without any negative inotropic effect. We present a case series of five patients with left ventricular dysfunction, admitted to our Intensive Cardiac Care Unit with ADHF deteriorated to cardiogenic shock, treated with a combination of landiolol and inotropes. Landiolol was effective in terms of rate control and haemodynamics optimization, enabling de‐escalation of catecholamine dosing in all patients. The infusion was always well tolerated without hypotension. In conclusion, a continuous infusion of a low dose of landiolol (3–16 mcg/kg/min) to manage tachycardia and ventricular or supraventricular tachyarrhythmias in haemodynamically unstable patients may be considered.

Anaphylactic shock in a patient with severe aortic stenosis treated with adrenaline and landiolol for circulatory management: A case report

RATIONALE

We present the first case of a patient with severe aortic stenosis who developed anaphylactic shock and was successfully treated with adrenaline and landiolol, a highly selective β1-receptor blocker, to prevent disruption of the myocardial oxygen supply-demand balance caused by tachycardia.

PATIENT CONCERNS

An 86-year-old woman was scheduled for simultaneous anterior-posterior fixation for a burst fracture of the 12th thoracic vertebra; 200 mg sugammadex, a neuromuscular blocking agent antagonist, was administered postoperatively, and she was extubated without complications. However, 6 min after extubation, her blood pressure decreased abruptly to 55/29 mm Hg, and her heart rate increased to 78 bpm. Then, we intervened with fluid loading, an increased dose of noradrenaline, and phenylephrine administration. However, her blood pressure did not increase.

DIAGNOSES

A general observation revealed urticaria on the lower leg; thus, we suspected anaphylactic shock due to sugammadex administration.

INTERVENTIONS

We carefully administered 2 doses of 0.05 mg adrenaline and simultaneously administered landiolol at 60 μg/kg/min to suppress adrenaline-induced tachycardia. Adrenaline administration resulted in a rapid increase in blood pressure to 103/66 mm Hg and a maximum heart rate of 100 bpm, suppressing excessive tachycardia.

OUTCOMES

The patient's general condition was stable after the intervention, and circulatory agonists could be discontinued the following day. She was discharged from the intensive care unit on the fourth postoperative day.

LESSONS

Landiolol may help control the heart rate of patients with aortic stenosis and anaphylactic shock. The combined use of landiolol and adrenaline may improve patient outcomes; however, their efficacy and risks must be evaluated by studying additional cases.