Rate control of atrial fibrillation (AF) during episodes of acute heart failure (AHF) with reduced left ventricular ejection fraction is clinically challenging. The LARISA randomized controlled trial evaluated whether an intensive rate control (IRC) strategy using the short-acting beta-blocker landiolol with adjunctive digoxin could provide faster and safe heart rate (HR) reduction and earlier symptomatic benefit compared with standard rate control therapy in this population.
LARISA was a randomized, multicenter trial reported in Eur Heart J Acute Cardiovasc Care. Forty patients presenting with AHF due to AF were enrolled. Key entry criteria included an HR greater than 130 beats per minute and an LVEF below 40%. Patients were randomized to either the protocolized IRC arm (landiolol plus digoxin) or to standard rate control therapy. The clinical trial registration number is ClinicalTrials.gov: NCT04694092.
The experimental arm combined intravenous landiolol, a short-acting intravenous beta-blocker, with adjunctive digoxin according to a protocolized intensive rate control strategy. The comparator was standard rate control therapy as practiced in the participating centers. Specific dosing regimens and stepwise titration details were not reported in the abstract.
The prespecified primary endpoint was achievement of a sustained HR reduction greater than 20% from baseline or an absolute HR below 115/min measured at 2 hours after randomization. Secondary assessments included haemodynamic measurements, relief of dyspnoea, and changes in lung congestion over serial assessments. Safety and adverse events including hypotension were also recorded.
IRC with landiolol plus digoxin achieved faster HR control compared with standard therapy. Median time to HR control was 1.5 hours in the IRC group versus 4 hours in the standard group (P = 0.016). At the 2-hour time point, the HR reduction was greater in the IRC arm (median 40% reduction) than in the standard therapy arm (median 23% reduction) (P = 0.045). The primary endpoint was met in 80% of patients receiving IRC versus 20% receiving standard therapy (P = 0.04).
Patients randomized to the landiolol-based IRC protocol experienced greater early symptomatic improvement, with more rapid dyspnoea relief and evidence of lung decongestion on serial assessment compared with those receiving standard rate control. The abstract reports these early clinical benefits were observed without deterioration in haemodynamics.
Importantly, the intensive rate control strategy using landiolol plus digoxin did not lead to excess hypotension or increased adverse events in this trial. Haemodynamic assessments were performed serially, and no safety signal attributable to the IRC protocol was reported in the abstract.
By 24 hours after randomization, outcomes between the IRC and standard therapy groups were similar. This indicates the principal advantage of the landiolol-based protocol was a more rapid initial HR reduction and earlier symptomatic improvement, whereas differences attenuated by 24 hours.
The data reported here are from the trial abstract. Detailed methodological elements such as specific dosing, titration steps, full haemodynamic numeric data, longer-term outcomes, and subgroup analyses were not included in the abstract and therefore are not reported here. The authors disclosed that one investigator received speaker honoraria; other authors declared no relevant disclosures.
In patients with AHF and reduced LVEF precipitated by AF with rapid ventricular response, a protocolized intensive rate control strategy using landiolol with adjunctive digoxin provided faster and greater early HR reduction and resulted in earlier symptomatic benefit compared with standard rate control, without excess hypotension or adverse events. By 24 hours, group outcomes were similar. The findings support consideration of a landiolol-based IRC approach for rapid rate control in this specific clinical scenario; clinicians should consult the full trial report for detailed dosing, titration, and broader context before changing practice.