Comparison of Esmolol Versus Landiolol on Mortality in Adult Patients With Sepsis: A Systematic Review and Network Meta-Analysis.

Summary

Across 10 RCTs (n=1,035), esmolol reduced 28-day mortality (RR 0.69, 95% CI 0.56–0.85) and heart rate versus standard care, while landiolol increased norepinephrine requirements versus SOC and was associated with higher 28-day mortality compared with esmolol (RR 1.57, 95% CI 1.08–2.30). Certainty was moderate for esmolol effects and low for landiolol comparisons.

Key Findings

• Esmolol reduced 28-day mortality versus standard care (RR 0.69, 95% CI 0.56–0.85; moderate certainty).
• Esmolol lowered 24-hour heart rate versus standard care (MD −16.92 bpm, 95% CI −23.49 to −10.36; moderate certainty).
• Landiolol increased norepinephrine use compared with standard care (MD 0.09 μg/kg/min, 95% CI 0.01–0.18; moderate certainty).
• Landiolol was associated with higher 28-day mortality versus esmolol (RR 1.57, 95% CI 1.08–2.30; low certainty).

Clinical Implications

Consider esmolol as the preferred short-acting β-blocker in septic patients requiring heart rate control, with close hemodynamic monitoring and awareness of catecholamine requirements; avoid extrapolating landiolol benefits until higher-certainty data are available.

Limitations

• Low certainty for landiolol comparisons and potential heterogeneity in dosing strategies.
• Limited head-to-head trials between esmolol and landiolol.

Future Directions

Conduct adequately powered head-to-head RCTs of esmolol versus landiolol with standardized titration protocols and patient-centered outcomes, and mechanistic studies to explain differential vasopressor effects.