Advancing Cardiovascular Management in Critical Care: A Focus on Vasopressors and Beta-Blockers

Clinical insights on the use of beta-blockers and vasopressors in the ICU, focusing on landiolol and vasopressin.

When managing cardiovascular instability in critically ill patients, intensivists often face a delicate balancing act: controlling heart rate without compromising haemodynamics and maintaining perfusion without excessive vasopressor burden.

In a recent AOP Health-sponsored symposium, leading experts gathered to share clinical insights on the use of beta-blockers and vasopressors in the ICU—particularly focusing on landiolol and vasopressin.

Beta-Blockers: Making the Case for Landiolol

Supraventricular arrhythmias such as atrial fibrillation are common in the ICU, often triggered by a complex interplay of sepsis, electrolyte disturbances, vasopressors, and mechanical ventilation. Rate control remains a cornerstone of management, but which agent offers the best safety-efficacy profile?

“Landiolol stands out because of its rapid onset, short half-life, and exceptional beta-1 selectivity,” explained Professor Olfa Hamzaoui (Reims University, France). “It provides reliable rate control with minimal impact on blood pressure—a critical feature in haemodynamically fragile patients.”

Unlike esmolol, landiolol shows significantly reduced negative inotropic effects, making it more suitable in patients with impaired left ventricular function or ongoing vasopressor support. Head-to-head comparisons and meta-analyses suggest landiolol may offer a better safety margin in the ICU setting.

Clinical studies have demonstrated:

• Effective control of atrial fibrillation with stable haemodynamics
• Potential reductions in norepinephrine doses
• Improved lactate clearance in some patient subgroups

While current guidelines draw from cardiology-based evidence, real-world ICU experience is beginning to shape a new perspective—one where selective beta-blockade plays a greater role in critical care.

Sepsis and Tachycardia: Can Beta-Blockers Help?

Landiolol has also been studied in the context of sepsis-induced tachycardia. Three major trials—LANDI-3S, STRESS-L, and LANDISEP (Kakikhana et al. 2020; Rehberg et al. 2024; Whitehouse et al. 2023)—evaluated whether controlling heart rate in septic shock might improve outcomes.

The results? Promising but not definitive. All three trials confirmed landiolol’s ability to reduce heart rate without worsening blood pressure. However, these physiological benefits did not consistently translate into improved survival—at least in the general septic shock population.

“We may be seeing signal in subgroups,” noted Professor Hamzaoui. “Patients with atrial fibrillation or a hypercontractile heart seem to benefit most. But clearly, more work is needed to identify the right targets.”

Vasopressin: Practical Insights from Real-World ICU Data

Shifting the focus to vasopressor therapy, Professor Arthur van Zanten (Netherlands) presented new data from an international registry exploring the use of vasopressin as a second-line agent in septic shock.

“There’s no universal definition of refractory shock,” said Professor van Zanten. “But most clinicians consider adding vasopressin when norepinephrine exceeds 0.25–0.50 µg/kg/min.”

The registry, which included 200 ICU patients across the Netherlands, Italy, and India, revealed:

• 80% response rate (defined as stabilisation or reduction of norepinephrine needs)
• Lower lactate levels predicted better outcomes
• Obese patients had reduced response, possibly due to fixed-dose vasopressin limitations
• Rebound hypotension occurred in just 9%, mostly when vasopressin was stopped early (<24h)

These findings underscore vasopressin’s potential to support haemodynamics, reduce catecholamine burden, and possibly limit complications like atrial fibrillation.

Optimising Therapy: The Road Ahead

What emerges from both presentations is a shift toward more nuanced, multimodal cardiovascular therapy in critical care. Instead of relying solely on norepinephrine, clinicians are exploring how agents like landiolol and vasopressin can be integrated into personalised haemodynamic strategies.

“We may be moving toward earlier, smarter combinations,” said Professor Chew (Karolinska Institute, Sweden), who moderated the session. “AI-based tools could help us identify the right patients sooner—before complications like arrhythmias or shock become harder to manage.”

Key Takeaways

• Landiolol is gaining ground as a preferred agent for rate control in ICU patients with atrial fibrillation, thanks to its excellent safety profile.
• In septic shock, landiolol may benefit selected patient groups
• Vasopressin, when used early and tapered appropriately, can effectively stabilise shock and reduce norepinephrine dependence.
• The future lies in individualised therapy, guided by clinical judgment, haemodynamic monitoring, and emerging decision-support tools.

This article is based on presentations delivered at an AOP Health-sponsored symposium on cardiovascular management in critical care during ISICEM. To watch the whole symposium, please follow this link: https://vimeo.com/1076392716/63bdf7e6a4

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.