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Heart rate reduction with esmolol is associated with improved arterial elastance in patients with septic shock: a prospective observational study

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Abstract

Purpose

Ventricular–arterial (V–A) decoupling decreases myocardial efficiency and is exacerbated by tachycardia that increases static arterial elastance (Ea). We thus investigated the effects of heart rate (HR) reduction on Ea in septic shock patients using the beta-blocker esmolol. We hypothesized that esmolol improves Ea by positively affecting the tone of arterial vessels and their responsiveness to HR-related changes in stroke volume (SV).

Methods

After at least 24 h of hemodynamic optimization, 45 septic shock patients, with an HR ≥95 bpm and requiring norepinephrine to maintain mean arterial pressure (MAP) ≥65 mmHg, received a titrated esmolol infusion to maintain HR between 80 and 94 bpm. Ea was calculated as MAP/SV. All measurements, including data from right heart catheterization, echocardiography, arterial waveform analysis, and norepinephrine requirements, were obtained at baseline and at 4 h after commencing esmolol.

Results

Esmolol reduced HR in all patients and this was associated with a decrease in Ea (2.19 ± 0.77 vs. 1.72 ± 0.52 mmHg l−1), arterial dP/dt max (1.08 ± 0.32 vs. 0.89 ± 0.29 mmHg ms−1), and a parallel increase in SV (48 ± 14 vs. 59 ± 18 ml), all p < 0.05. Cardiac output and ejection fraction remained unchanged, whereas norepinephrine requirements were reduced (0.7 ± 0.7 to 0.58 ± 0.5 µg kg−1 min−1, p < 0.05).

Conclusions

HR reduction with esmolol effectively improved Ea while allowing adequate systemic perfusion in patients with severe septic shock who remained tachycardic despite standard volume resuscitation. As Ea is a major determinant of V–A coupling, its reduction may contribute to improving cardiovascular efficiency in septic shock.

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Authors and Affiliations

  1. Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, University of Rome, “La Sapienza”, Policlinico Umberto Primo, Viale del Policlinico 155, 00161, Rome, Italy

    A. Morelli, V. M. Ranieri, A. D’Egidio, A. Orecchioni, F. Piscioneri & E. Greco

  2. Bloomsbury Institute of Intensive Care Medicine, University College London, Cruciform Building, London, WC1E 6BT, UK

    M. Singer

  3. Department of Anesthesia and Intensive Care, Cardiothoracic Anesthesia and Intensive Care Medicine, University Hospital of Pisa, via Roma 55, 56126, Pisa, Italy

    F. Guarracino

  4. Department of Medico-Surgical Sciences and Biotechnologies, University of Rome “La Sapienza”, Corso della Repubblica, 79, 04100, Latina, Italy

    L. Mascia, M. Peruzzi, G. Biondi-Zoccai & G. Frati

  5. Department of AngioCardioNeurology, IRCCS Neuromed, Via Atinense 18, 86077, Pozzilli, Italy

    G. Biondi-Zoccai & G. Frati

  6. Unit of Internal Medicine and Cardiology, Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 3, 50134, Florence, Italy

    S. M. Romano

Authors
  1. A. Morelli
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  2. M. Singer
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  3. V. M. Ranieri
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Corresponding author

Correspondence to A. Morelli.

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Conflicts of interest

Andrea Morelli received honoraria for speaking at Baxter symposia. Mervyn Singer served as a consultant and received honoraria for speaking and chairing symposia for Baxter. Salvatore Mario Romano has a patent “Method and apparatus for measuring cardiac flow output” (USA Patent Number 6758822). No other disclosures were reported.

Additional information

Take-home message: Despite achieving recommended hemodynamic targets, ventricular-arterial decoupling may persist in patients with septic shock and it can deteriorate progressively during the course of the disease. Such patients may potentially benefit from therapies aimed at normalizing V–A coupling. Among them, HR reduction with esmolol could effectively improve Ea while allowing adequate systemic perfusion in septic shock patients remaining tachycardic despite standard resuscitation. As Ea is a major determinant of V–A coupling, its reduction may contribute to improving cardiovascular efficiency in septic shock.

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Morelli, A., Singer, M., Ranieri, V.M. et al. Heart rate reduction with esmolol is associated with improved arterial elastance in patients with septic shock: a prospective observational study. Intensive Care Med 42, 1528–1534 (2016). https://doi.org/10.1007/s00134-016-4351-2

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  • DOI: https://doi.org/10.1007/s00134-016-4351-2

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