A
recent review concluded that acute heart failure (HF) induced by rapid atrial
fibrillation (rapid AF) presents a critical dilemma due to conflicting
guideline recommendations on heart rate control. While HF guidelines urge
caution against the negative inotropic effects of β-blockers in acute
decompensation, evidence supports that short-acting,
highly selective β-blockers
(such as landiolol) are significantly superior to digitalis for rapid
ventricular rate control without compromising safety in hemodynamically stable
patients.
This
narrative review is published in the American
Heart Journal Plus: Cardiology Research and Practice, in December
2025.
The
cautious and closely monitored use of these titratable, short-acting agents
provides a necessary strategy for breaking the vicious cycle of rapid
AF-induced heart failure.
Atrial fibrillation (AF) and heart failure
(HF) Overlap & Guideline Disparity
Atrial fibrillation (AF) and heart failure (HF) frequently
coexist, substantially increasing mortality and hospitalization. Rapid AF often
triggers acute HF decompensation by driving excessively fast ventricular rates,
reducing cardiac output, restricting ventricular filling, and potentially
causing tachycardia-induced cardiomyopathy (TICM). Rapid and effective
ventricular rate control is therefore crucial. Traditional rate-control options
include digitalis and β-blockers.
However, clinicians face conflicting guidance:
- AF Guidelines: View β-blockers as foundational for ventricular rate control in
AF with HF and recommend urgent reduction of resting heart rate to <110 bpm
(Class IIa). - HF Guidelines: Advise major caution—β-blockers should only be started or
uptitrated after hemodynamic stabilization, improvement of congestion, and
restoration of normal volume status because their negative inotropic effect may
worsen low cardiac output and tissue hypoperfusion.
Applying Short-Acting β-blockers
Agents
This
review systematically addresses this conflict by analyzing guideline
recommendations and pooling relevant research, focusing on the application
strategies of short-acting β-blockers. The rationale for using these
agents rests on the principle that worsening ventricular function caused by
rapid AF is usually reversible
if the ventricular rate is controlled promptly, thus reversing conditions like
TICM.
The
key strategy involves utilizing new, controllable β-blockers, namely esmolol and landiolol. Both are intravenous preparations characterized by
rapid onset of action and extremely short half-lives (minutes). This allows for
precise heart rate titration through continuous intravenous infusion, with
effects quickly subsiding upon discontinuation, thereby avoiding long-term
adverse effects in the acute setting.
Evidence Supporting Short-Acting β-blockers
in Acute Settings
Clinical
evidence strongly supports the benefits of short-acting β-blockers in
this acute setting:
•
J-Land Study: This Japanese
multicenter randomized trial compared the ultra-short-acting β1-selective
blocker landiolol with digoxin
for emergency heart rate control in patients with rapid AF and
moderate-to-severe HF (EF 25–50 %). Landiolol was significantly superior,
successfully reducing the heart rate to <110 beats per minute within 2 hours
in 48% of patients versus 13.9% for digoxin (P<0.001). Crucially,
there was no significant difference in the incidence of adverse events between
the two groups.
•
Landiolol’s Superiority:
Landiolol has ultra-high β1 selectivity (8 times that of esmolol) and a
shorter half-life (approximately 4 min). Its high selectivity means it has less impact on blood pressure and relatively
weaker negative inotropic effects, making it particularly beneficial for
patients with heart failure.
•
Esmolol: Although less selective
than landiolol, esmolol (half-life ∼9 min) remains a preferred short-acting agent
where landiolol is unavailable, especially in patients with mild-to-moderate
acute HF and a systolic blood pressure >100 mmHg.
Short-Acting β-blockers in Acute
Settings – Key Clinical Considerations:
•
Contraindication: β-blockers
are strictly contraindicated (Class
III) in patients with hemodynamic instability, hypotension
(systolic BP<90 mmHg), or poor organ perfusion. The circulation
must be stabilized first.
•
Targeted Use: Landiolol, due to
its high selectivity and minimal blood pressure impact, is suggested to be more
suitable for acute HF patients with “fair
blood pressure and a non-enlarged heart”.
•
Combined Therapy: Early studies
suggest that the combined use of Landiolol and Dobutamine may effectively
control heart rate while maintaining cardiac output in patients with low
cardiac output and AF, though this requires close ICU monitoring.
•
Individualization: Clinicians
must carefully assess patient-specific factors, including the severity of heart
failure and comorbidities, before initiation, striving for an individualized
approach that minimizes risks and optimizes treatment outcomes.
In
summary, the emergence of ultra-short-acting β-blockers provides the
necessary therapeutic flexibility
to control rapid AF in acute heart failure safely, achieving the critical goal
of “fast and stable” rate control to reverse cardiac dysfunction.
Clinical Implications
For
practicing cardiologists, the evidence supports the cautious application of
these specific short-acting β-blockers when used under strict monitoring to
facilitate HF stabilization.
Reference: Zhu W, Xu J, Zhang L. The controversies in the clinical
management of β-blockers in acute heart failure induced by rapid atrial
fibrillation: A narrative review. Am Heart J Plus. 2025 Oct 24;60:100655. doi:
10.1016/j.ahjo.2025.100655. PMID: 41282304; PMCID: PMC12634828.
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