Use of landiolol in septic shock patients with new onset of atrial fibrillation: A European Delphi Consensus

Background: New-onset atrial fibrillation (NOAF) frequently complicates septic shock and is associated with haemodynamic instability, prolonged intensive care unit stay, and increased mortality. Despite its clinical relevance, guidance on heart rate (HR) management remains limited, particularly regarding the use of ultra-short-acting β₁-blockers. To reduce variability in clinical practice, a European multidisciplinary panel developed a consensus on the management of atrial fibrillation in septic shock, with a focus on landiolol. Methods: A modified RAND/UCLA Delphi methodology was applied. Nine European experts in intensive care, anaesthesiology, and cardiology participated in two Delphi rounds. Fifty-five statements across nine thematic areas were evaluated using a 9-point Likert scale. Consensus was predefined as ≥80% agreement within the same scoring range. Results: Overall, 70.9% of statements achieved consensus and were included in the final recommendations. Consensus supported the correction of reversible triggers of atrial fibrillation, haemodynamic assessment before HR control, and an individualised cardioversion strategy. Landiolol was endorsed for HR control in selected septic shock patients with NOAF, given its high β₁-selectivity and rapid titratability. Consensus supported initiation without bolus, starting at low doses gradually titrated, to an initial HR target below 110 bpm, guided by close haemodynamic and echocardiographic monitoring. No consensus was reached on the optimal duration of landiolol therapy or its use in patients with severe ventricular dysfunction. Conclusions: This Delphi consensus provides pragmatic, physiology-driven recommendations for the management of NOAF in septic shock, supporting clinical decision-making in complex real-world settings where evidence remains limited.