Redefining Rate Control Strategy With Landiolol: Manage the Rhythm Without Compromising the System

• In ICU
• Tue, 14 Oct 2025

ICU Management & Practice, Volume 25 - Issue 4, 2025

Landiolol, an ultra-short-acting and highly β1-selective intravenous β-blocker, addresses the need for rapid and controllable arrhythmia suppression while maintaining cardiovascular stability. Recently approved in the United States and already in use in Europe, landiolol combines rapid onset and offset with a favourable haemodynamic profile.

Tachyarrhythmias frequently complicate the clinical course of critically ill patients, contributing to haemodynamic deterioration and increased morbidity and mortality, particularly following cardiac surgery or acute myocardial infarction. Therapeutic management necessitates effective rate and rhythm control; however, the use of conventional β-adrenergic blockers and amiodarone is often limited by their potential to exacerbate hypotension, negative inotropy, and other adverse effects. This underscores the need for agents that provide rapid, controllable arrhythmia suppression while preserving cardiovascular stability.

Landiolol, a highly β1-selective and ultra-short-acting intravenous β-blocker, is emerging as a solution to this dilemma. Recently approved in the United States and already integrated into European practice, landiolol combines rapid onset and offset with a favourable haemodynamic profile (Frishman et al. 2025; Rao et al. 2024). New publications across a range of clinical settings suggest landiolol could redefine rate control strategies in the ICU.

Pharmacological Profile: Precision and Safety

The pharmacological profile of landiolol, characterised by rapid onset and offset, makes it an ideal β-blocker for patients with unstable haemodynamics who require immediate and adjustable rate control:

• Half-life of just 4 minutes, allowing real-time titration (Nasoufidou et al. 2025).
• High β1-selectivity (~8 times higher than esmolol), minimising negative inotropy and bronchospasm (Rao et al. 2024).
• Predictable kinetics, with minimal protein binding and no clinically significant metabolites (Frishman et al. 2025).

This “on-off switch” pharmacological profile provides clinicians with the ability to swiftly titrate or discontinue therapy, offering a significant safety advantage in the critical care setting.

 

Supraventricular Arrhythmias

Placebo-controlled trials formed the basis for FDA approval, confirming that landiolol rapidly and effectively reduces heart rate in supraventricular tachycardias, including atrial fibrillation and flutter (Frishman et al. 2025).

Compared to esmolol, landiolol demonstrates superior cardioselectivity and comparable efficacy, with hypotension the most frequent but usually reversible side effect. This allows safe use even in fragile patients with severe reduced ventricular function (Frishman et al. 2025).

Coronary Artery Disease and STEMI

In acute coronary syndromes, heart rate control can stabilise haemodynamics and reduce myocardial oxygen demand. A 2025 review in Journal of Clinical Medicine summarised promising findings (Nasoufidou et al. 2025):

• In ST-elevation myocardial infarction (STEMI), landiolol reduced progression to higher Killip classes and lowered the incidence of acute heart failure compared with placebo.
• During CT coronary angiography, bolus or infusion regimens enabled target heart rates for high-quality imaging without compromising blood pressure.

Meta-analyses further suggest that early intravenous β-blockade, particularly with landiolol, may improve outcomes even in the percutaneous coronary intervention (PCI) era (Sun et al. 2024). This positions landiolol as a practical and potentially protective option for critically ill coronary patients.

Ventricular Tachycardia and Electrical Storm: A Difficult Setting

Electrical storm (ES) remains one of the most challenging arrhythmia emergencies. Evidence is sparse, but three Japanese studies and a post-marketing survey of 250 patients showed landiolol to be effective in suppressing ES episodes, often in combination with amiodarone (Motazedian et al. 2025).

Landiolol represents a new and useful agent in the critical care armamentarium for managing patients refractory to amiodarone. It is an alternative for unstable patients at risk for hypotension who are not eligible for sedation or stellate ganglioplegia when under anticoagulant therapy.

Although larger randomised trials are needed, existing data suggest that landiolol may serve as an effective adjunctive therapy in cases where conventional treatments are insufficient.

Preventing Postoperative Atrial Fibrillation

Postoperative atrial fibrillation (POAF) is among the most prevalent complications following cardiac surgery and is associated with prolonged intensive care unit (ICU) stays and delayed overall recovery. Here, landiolol demonstrates some of the most robust clinical evidence:

• A systematic review found landiolol reduced POAF from 37.6% to 13.7% in cardiac surgery patients (Fellahi et al. 2025).
• A large retrospective analysis reported significantly lower POAF incidence (18.9% vs 38.7%) and shorter hospital stays with landiolol (Kaminohara et al. 2022).

Considering the adverse effect profile of amiodarone and the frequent hesitation to resume conventional β-blockers postoperatively due to hypotension risk, landiolol’s favourable haemodynamic properties and safety profile present it as a viable and well-tolerated option for the prevention of POAF.

Beyond Cardiac Surgery: ERAS and Thoracic Surgery

Enhanced Recovery After Surgery (ERAS) protocols emphasise multimodal optimisation. A 2025 study demonstrated ERAS reduced POAF incidence, and authors noted that safer short-acting agents like landiolol could increase clinician confidence in guideline-adherent β-blocker use (Niessen et al. 2025).

In thoracic surgery, including lung resection, case reports describe landiolol’s effectiveness in reducing heart rate and restoring sinus rhythm, without exposing patients to amiodarone’s pulmonary toxicity risks (Sauve et al. 2025).

Safety Profile and Practical Considerations

Landiolol is generally well tolerated, with a safety profile favourable compared to other intravenous β-blockers. The most frequently reported adverse event is hypotension, which is usually mild, transient, and reversible upon dose adjustment or discontinuation of the infusion (Frishman et al. 2025). Bradycardia may also occur, consistent with class effects of β1-selective blockers, but is typically manageable and rarely necessitates treatment cessation (Frishman et al. 2025).

Practical dosing considerations:

• Initiate therapy at 1–10 mcg/kg/min, with the starting dose guided by the patient’s baseline ventricular function.
• Titrate every 10–15 minutes based on therapeutic response and tolerability.
• In patients with preserved haemodynamics, upward titration can be achieved safely due to landiolol's rapid onset and offset.

Transition to oral β-blockers can be facilitated smoothly due to landiolol’s rapid clearance, allowing seamless maintenance of rate or rhythm control after stabilisation (Frishman et al. 2025).

This flexibility in dosing and rapid reversibility makes landiolol particularly well-suited for perioperative arrhythmia management, including POAF, where haemodynamic parameters can shift rapidly.

Conclusion

Landiolol has emerged as a clinically valuable agent across diverse cardiovascular contexts, including supraventricular arrhythmias, STEMI, electrical storm, and POAF. Its ultra-short-acting β₁-selective profile offers reliable rate control with minimal impact on blood pressure and myocardial contractility, making it particularly advantageous in patients with compromised haemodynamics. Landiolol is a useful agent to manage beta-blockade during critical care stay, avoiding discontinuation or optimising early initiation as recommended.

The ability to titrate rapidly and discontinue the drug promptly provides clinicians with a high degree of control, especially in critical care and perioperative settings. Although further large-scale, comparative trials are warranted to refine its positioning among existing therapies, current evidence supports landiolol as a safe, effective, and flexible option for acute heart rate management in complex and unstable cardiovascular conditions.

Disclaimer

Point-of-view articles are the sole opinion of the author(s) and are part of the ICU Management & Practice Corporate Engagement or Educational Community Programme.

References:

Fellahi JL, Fischer MO, Ruste M, Jacquet-Lagreze, M. Prevention and Treatment of New-Onset Postoperative Atrial Fibrillation in the Acute Care Setting: A Narrative Review. Preprints 2025;2025080096.

Frishman WH, Amir J, Rosman R. Landiolol (Rapiblyk), A Newly Approved, Ultra-Short Acting Intravenous β1-Adrenoreceptor Blocker for the Treatment of Supraventricular Arrhythmias. Cardiol Rev. 2025.

Kaminohara J, Hara M, Uehara K, Suruga M, Yunoki K, Takatori M. Intravenous landiolol for the prevention of atrial fibrillation after aortic root, ascending aorta, and aortic arch surgery: A propensity score-matched analysis. JTCVS Open. 2022;11:49-58. 

Motazedian P, Prosperi-Porta G, Mathieu ME, Beauregard N, Knoll W, Quinn N, Parlow S, Di Santo P, Abdel-Razek O, Jung R, Kolobaric N, Barbour W, Nelson D, Simard T, Jentzer JC, Mathew R, Wells GA, Ramirez FD, Hibbert B. The lack of evidence-based management in electrical storm: a scoping review. BMC Cardiovasc Disord. 2025;25(1):556. 

Nasoufidou A, Bantidos MG, Stachteas P, Moysidis DV, Mitsis A, Fyntanidou B, Kouskouras K, Karagiannidis E, Karamitsos T, Kassimis G, Fragakis N. The Role of Landiolol in Coronary Artery Disease: Insights into Acute Coronary Syndromes, Stable Coronary Artery Disease and Computed Tomography Coronary Angiography. J Clin Med. 2025;14(15):5216. 

Niessen R, Rancati V, Verdugo-Marchese M, Gunga Z, Nowacka A, Melly V, Abellan C, Alouazen K, Abdurashidova T, Botteau C, Kirsch M, Ltaief Z. Effect of Enhanced Recovery After Surgery (ERAS) Implementation on Postoperative Atrial Fibrillation in Cardiac Surgery. Biomedicines. 2025;13(5):1212. 

Rao SJ, Kanwal A, Kanwal A, Danilov A, Frishman WH. Landiolol: An Ultra-Short-Acting β-Blocker. Cardiol Rev. 2024;32(5):468-472. 

Sauve J, et al. Postoperative Atrial Fibrillation Following Anatomic Lung Resection. Cureus. 2025.

Sun B, Wang CY, Chen RR. Clinical Efficacy and Safety of Early Intravenous Administration of Beta-Blockers in Patients Suffering from Acute ST-Segment Elevation Myocardial Infarction Without Heart Failure Undergoing Primary Percutaneous Coronary Intervention: A Study-Level Meta-Analysis of Randomized Clini