Urgent Control of Rapid Atrial Fibrillation by Landiolol in Patients With Acute Decompensated Heart Failure With Severely Reduced Ejection Fraction

Abstract

Background: We investigated the clinical usefulness of landiolol for rapid atrial fibrillation (AF) in patients with acute decompensated heart failure (ADHF) and identify the patients eligible for landiolol. Methods and Results: A total of 101 ADHF patients with reduced ejection fraction (HFrEF) with rapid AF were enrolled. Immediately after admission, an initial dose of landiolol was given (1 μg/kg^-1/min^-1), and then the dose was increased to decrease heart rate (HR) to <110 beats/min and change HR (∆HR) >20% in ≤24 h. Thirty-seven were monitored using right heart catheterization at 3 points (baseline, 1 μg/kg^-1/min^-1, and maximum dose). We checked the major adverse events (MAE) during initial hospitalization, which included cardiac death, HF prolongation (required i.v. treatment at 30 days), and worsening renal function. The average maximum dose of landiolol was 3.8±2.3 μg/kg^-1/min^-1. HR (P<0.0001) and pulmonary capillary wedge pressure (P=0.0008) decreased safely. MAE occurred in 39 patients. The patients with left ventricular (LV) end-diastolic volume index <84.0 mL/m² and mean blood pressure (mean BP) >97 mmHg had less frequent MAE (P<0.0001). Conclusions: Landiolol was effective for safely controlling rapid AF in patients with HFrEF with ADHF, leading to hemodynamic improvement and avoidance of short-term MAE, especially in patients with relatively smaller LV and higher BP.

Keywords: Atrial fibrillation; Beta-blocker; Echocardiography; Heart failure; Prognosis.

Figure 1.

Study protocol. A total of 101 patients underwent landiolol treatment with continuous electrocardiographic monitoring. All 101 patients underwent echocardiographic evaluation and were checked and biochemical marker before starting treatment. The initial dose was 1 μg/kg⁻¹/min⁻¹ titrated to a maximum dose of 10 μg/kg⁻¹/min⁻¹ every 2 h according to the patient’s condition. The target HR was 110 beats/min and 20% reduction in HR from the baseline. All the patients’ HR and blood pressure (37 patients underwent RHC monitoring) were measured at baseline, initial dose, and maximum dose. ADHF, acute decompensated heart failure; HF, heart failure; HR, heart rate; MAE, major adverse events; RHC, right heart catheterization; WRF, worsening renal function.

Figure 2.

(A) Prediction of major adverse events (MAE) according to median mean blood pressure (BP; 97 mmHg) and median left ventricular end-diastolic volume index (LVEDVI; 84.0 mL/m²) in 101 patients. Group A, LVEDVI <84.0 mL/m² and mean BP >97 mmHg; group B, LVEDVI ≥84.0 mL/m² and mean BP >97 mmHg; group C, LVEDVI <84.0 mL/m² and mean BP ≤97 mmHg; and group D, LVEDVI ≥84.0 mL/m² and mean BP ≤97 mmHg. Blue plots, patients without MAE (n=62); red plots, patients with MAE (n=39). (B) This figure shows the number of each of the four categories in (A). Fisher’s exact test shows that each category had significant relationships with the presence of MAE (Fisher’s exact test, P<0.0001).

Figure 3.

Change in pulmonary capillary wedge pressure (PCWP) according to reduction in heart rate (HR) due to landiolol treatment (arrows). Of 37 patients, 34 had decreased PCWP ≤24 h after landiolol treatment.