Esmolol for Tachyarrhythmia Management in Critically Ill Patients

Abstract

Introduction: Supraventricular tachyarrhythmias, particularly atrial fibrillation, occur frequently in critically ill patients and may worsen hemodynamics. This review assesses esmolol’s efficacy and safety for acute rate control in the intensive care unit.

Methods: Systematic review of observational studies and randomized trials of intravenous esmolol versus placebo, amiodarone, or digoxin for acute rate control in adult ICU patients with new-onset atrial fibrillation or atrial flutter. Primary outcome was heart rate reduction to <110 beats per minute within 60 minutes. Secondary outcomes included hypotension requiring intervention.

Results: Nine studies (857 patients) met inclusion. Esmolol achieved target heart rate in 82% of patients compared to 53% for digoxin and 67% for amiodarone, with median time to control of 18 minutes. Hypotension occurred in 14% of esmolol recipients, usually within 15 minutes of bolus administration and reversible with fluid or bolus cessation. No differences in stroke or mortality were observed.

Discussion: Esmolol’s ultra-short half-life (9 minutes) allows rapid titration and quick reversal if hypotension occurs. It is particularly useful when beta-blockade is desirable but hemodynamic instability is a concern. Most studies excluded patients with acute decompensated heart failure or severe aortic stenosis, limiting generalizability.

Conclusions: Esmolol provides rapid and effective rate control for ICU supraventricular tachyarrhythmias with a predictable hypotensive risk that is quickly reversible. It is a first-line option when immediate rate control is needed.