Ultra-Short β-Blockers Deliver Rapid Stability in AF-Triggered Acute Heart Failure, AHJP December 2025 Review

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:

1. 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).
2. 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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