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

Use of landiolol in septic shock patients with new onset of atrial fibrillation: A European Delphi Consensus | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Use of landiolol in septic shock patients with new onset of atrial fibrillation: A European Delphi Consensus Fabio Guarracino, Bruno Levy, Martin Balik, Michael Fries, Michael Joannidis, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9269792/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 11 You are reading this latest preprint version Abstract 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. Atrial fibrillation Septic shock Landiolol Figures Figure 1 Background Atrial fibrillation (AFib) and septic shock frequently intersect in the intensive care setting, posing major challenges for both management and prognosis. Systemic inflammation is a key driver of new-onset AFib (NOAF), which occurs in approximately 25–30% of patients with septic shock ( 1 ). The haemodynamic instability resulting from inflammation increases the risk of AFib and may exacerbate cardiac dysfunction and organ failure ( 2 – 4 ). Patients developing NOAF during septic shock tend to have worse outcomes, including prolonged intensive care unit (ICU) stay and higher mortality ( 5 – 7 ). While the 2020 and 2024 ESC Guidelines define AFib management as a comprehensive strategy encompassing stroke prevention, rate and rhythm control, and risk factor modification ( 8 , 9 ), this paradigm shifts in critically ill patients. In ICU patients with NOAF, rhythm control is often prioritised, although treatment decisions should be individualised and guided by haemodynamic status and bedside echocardiographic assessment ( 10 ). Nonetheless, the pharmacological agents commonly recommended for heart rate (HR) control - such as beta-blockers, non-dihydropyridine calcium-channel blockers, and digoxin - may be poorly tolerated in this population due to frequent haemodynamic compromise, including hypotension and ventricular dysfunction ( 8 , 9 ). Among commonly used beta-blockers, including metoprolol and esmolol, landiolol combines high β1-selectivity with a rapid-acting and short-lasting pharmacokinetic profile (Supplementary Table 1 and Paragraph “Pharmacological profile of landiolol”). These features may help limit hypotensive and off-target organ effects while allowing better titratability and reversibility of adverse effects ( 11 ). Landiolol has been associated with good tolerability and faster HR control when compared to digoxin, for treatment patients in acute heart failure with AFib ( 12 ). In the setting of septic shock, landiolol has been shown to effectively control HR without increasing vasopressor requirements, while supporting the restoration of sinus rhythm and improving organ perfusion ( 13 – 18 ). Evidence also suggests that landiolol may mitigate catecholamine-induced inflammation and improve metabolic homeostasis ( 19 – 23 ). Current ESC guidelines do not provide specific recommendations for the management of Afib in patients with septic shock or for the use of ultra-short-acting beta-blockers such as landiolol in this setting ( 8 , 9 ). This lack of guidance contributes to marked heterogeneity in clinical practice, particularly among clinicians less familiar with the management of NOAF in critically ill patients. During an Advisory Board held in Vienna on 6 May 2024, experts agreed that a Delphi consensus process would be the most appropriate approach to reduce this variability and provide practical, experience-based recommendations. As a result, a multidisciplinary group of European experts in anaesthesiology, intensive care, and cardiology was convened to develop a RAND/UCLA Delphi consensus-based guidance on the safe and effective use of landiolol in septic patients with NOAF. The scope was limited to AFib in septic shock, excluding cases with sinus tachycardia (e.g., STRESS-L population), and all recommendations were designed to align with international AFib guidelines ( 8 , 9 ). The guidance was intentionally conservative, avoiding complex interventions reserved for expert centres. Pharmacological profile of landiolol Landiolol is an aryloxypropanolamine beta-blocker characterised by very high β1-selectivity (β1/β2 ≈ 250) and an ultra-short duration of action, with a plasma half-life of 3-4 minutes. It is rapidly hydrolysed by plasma pseudocholinesterases and administered via continuous intravenous infusion, allowing for tight titration and prompt discontinuation if needed (13, 24). These pharmacokinetic properties translate into a rapid onset and offset of action, contributing to good haemodynamic tolerability - even in patients with left ventricular dysfunction or on vasopressors. Methods This project was conducted following a structured process based on a modified RAND/UCLA Delphi methodology. Board A Scientific Board composed of nine experts in anaesthesiology, intensive care, and cardiology - each with recognised experience in the management of AFib and critically ill patients - was convened to support the development of the consensus. The members were selected to ensure a multidisciplinary perspective and broad geographical representation across Europe. Supplementary Table 2 displays the list of the members of the Scientific Board. Two of the members of the Scientific Board (Prof. Fabio Guarracino and Michel Slama) chaired the initiative and constituted the Editorial Board, responsible for defining the scientific criteria, identifying the thematic areas to be explored, and conducting the literature search necessary for the development of the Delphi questionnaire. The Scientific Board reviewed the selected topics and contributed to the formulation of consensus statements. An independent methodologist (Dr. Alessandro Urbani), with expertise in systematic reviews, meta-analyses, and the Delphi method, participated in both Boards. Delphi questionnaire definition and Delphi poll A comprehensive literature search and review was conducted by the Editorial Board. Based on the literature review, the questionnaire was validated during the first meeting of the Scientific Board and comprised 55 initial statements across nine thematic areas (Table 1 ). Table 1 Distribution of statements across thematic areas. Thematic area Number of statements 1. Treatment of potential triggers of AFib in septic shock patient. 13 2. Haemodynamic assessment in septic shock patient before HR control. 3 3. Individualised cardioversion approach to AFib in critically ill patients. 7 4. Pharmacological approach to AFib in critically ill patients. 10 5. Titration of landiolol and HR goal to reached. 9 6. Duration of therapy with landiolol. 2 7. Therapy after stopping landiolol. 4 8. Alternative option in case of partial success or failure with landiolol. 4 9. Landiolol and concomitant use of positive inotropic agents. 3 The Delphi poll was discussed in two Rounds (web meetings in March and June 2025). Figure 1 displays the structure of the project. The Board rated their level of agreement with each statement using a 9-point Likert scale (1 = maximum disagreement; 9 = maximum agreement). Agreement was defined as ≥ 80% of responses falling within the same three-point region (1–3, 4–6, or 7–9). Disagreement was defined as ≥ 85% of responses distributed across the two wide regions (1–6 or 4–9). Statements that did not meet the agreement criterion were subjected to elimination or rewording. In Round 1, statements that reached agreement were retained without modifications. In Round 2 clinical experts re-evaluated the statements that did not reach consensus in Round 1. The methodologist analysed and summarised the results while keeping the individual ratings anonymous. Ethical considerations This Delphi study did not involve human participants, patients, or personal health data. Therefore, in accordance with applicable ethical standards and institutional policies, formal approval by an Ethics Committee was not required. All experts participated voluntarily and anonymously in the consensus process. Results The Scientific Board evaluated the 55 statements through two Delphi Rounds. In Round 1, agreement was reached on 23 statements (41.8%). Of the remaining 32 statements, 7 (12.7%) were excluded due to lack of consensus, while 25 (45.5%) were revised and carried forward to Round 2 (Supplementary Table 3). In Round 2, consensus was achieved for 16 out of 25 remaining statements, while 9 did not reach consensus (Supplementary Table 4). Overall, 39 of the 55 statements (70.9%) were included in the final recommendations, and 16 (29.1%) were excluded across the two Rounds. Results are presented below by thematic area. For each area, tables report statements reaching agreement and those classified as disagreement but retained. Supplementary Tables 3 and 4 provide the complete list of statements and outcomes across both Rounds. Treatment of potential triggers of AFib in septic shock patient (Table 2 ): The agreement was reached on 12 out of 13 statements; Haemodynamic assessment in septic shock patient before HR control (Table 3 ): full consensus across all three statements; Individualised cardioversion approach to AFib in critically ill patients (Table 4 ): The experts agreed on 6 of 7 statements, with one statement remaining in disagreement; Pharmacological approach to AFib in critically ill patients (Table 5 ): Four of 10 statements were agreed upon, while 6 did not reach consensus; Titration of landiolol and HR goal to reached (Table 6 ): Area 5 saw agreement with 7 out of 9 statements achieving consensus; Duration of therapy with landiolol (Table 7 ): Area 6 did not reach agreement on its two statements, despite attempts to reword them; Therapy after stopping landiolol (Table 8 ): Consensus was achieved with all 4 statements; Alternative option in case of partial success or failure with landiolol (Table 9 ): Consensus was reached on 2 of 4 statements; Landiolol and concomitant use of positive inotropic agents (Table 10 ): Only 1 of 3 statements accepted. Table 2 Final results of Area 1 - Treatment of potential triggers of AFib in septic shock patient. Statement N. respondents % 7–9 % 4–6 % 1–3 % 4–9 % 1–6 Result 1. At first presentation of septic shock patient, is key important to identify all triggers of AFib before starting any treatments to control HR. 7 100.0% 0.0% 0.0% 100.0% 0.0% Agreement 2. At first presentation of septic shock patient, hypovolemia should be identified and corrected before starting controlling HR. 7 100.0% 0.0% 0.0% 100.0% 0.0% Agreement 3. At first presentation of septic shock patient, withdrawal of beta-blockers should be identified as potential trigger. 7 85.7% 0.0% 14.3% 85.7% 14.3% Agreement 4. At first presentation of septic shock patient with AFib, pain or anxiety (e.g. postoperative) should be detected before starting controlling HR. 8 87.5% 0.0% 12.5% 87.5% 12.5% Agreement 5. At first presentation of septic shock patient, hypokalaemia should be identified and corrected before starting controlling HR. 7 85.7% 0.0% 14.3% 85.7% 14.3% Agreement 6. At first presentation of septic shock patient with AFib, suspected hypomagnesemia may be identified and corrected before starting controlling HR with landiolol, but without delaying in case of haemodynamic instability. 8 87.5% 0.0% 12.5% 87.5% 12.5% Agreement 7. In case of AFib in stabilised septic shock patient, doses of catecholamine (vasopressors, inotrope) should be revaluated and non-catecholamine vasopressors (e.g. vasopressin) may be considered as it allows to decrease catecholamine doses and HR along with contemplating starting controlling HR. 8 100.0% 0.0% 0.0% 100.0% 0.0% Agreement 8. At first presentation of septic shock patient with AFib, high fever should be detected and could be treated before starting controlling HR but without delaying in case of haemodynamic instability. 8 87.5% 12.5% 0.0% 100.0% 12.5% Agreement 10. At first presentation of septic shock patient with AFib, severe anaemia and in absence of hypovolemia should be identified, and its management should be initiated along with starting controlling HR, and without delay in case of haemodynamic instability. 8 100.0% 0.0% 0.0% 100.0% 0.0% Agreement 11. At first presentation of septic shock patient with AFib, myocardial ischemia should be detected and treated, but HR control should not be delayed as tachycardia contributes to increase DO2/VO2 imbalance and induce further critical ischemia. 8 87.5% 12.5% 0.0% 100.0% 12.5% Agreement 12. Endocrine disorders (pheochromocytoma or elevated thyroid hormones) should be investigated in the context of HR control as a potential trigger to further adjust patient management. 8 100.0% 0.0% 0.0% 100.0% 0.0% Agreement 13. At first presentation of septic shock patient, severe hypothermia should be identified and corrected before starting controlling HR 7 85.7% 14.3% 0.0% 100.0% 14.3% Agreement Table 3 Final results of Area 2 - Haemodynamic assessment in septic shock patient before HR control. Statement N. respondents % 7–9 % 4–6 % 1–3 % 4–9 % 1–6 Result 14. Determination of haemodynamic parameters with continuous HR and BP and is the minimum requirement to control patient response/condition, and advanced monitoring for cardiac assessment is recommended. 8 87.5% 12.5% 0.0% 100.0% 12.5% Agreement 15. Clinical monitoring of tissue perfusion is important when reducing HR rate (the more HR is reduced the tighter the control of tissue perfusion has to be checked: lactate, capillary refill time test, ScvO2 and /or Delta pCO2). 7 100.0% 0.0% 0.0% 100.0% 0.0% Agreement 16. Invasive and/or non-invasive tools can be used to assess haemodynamic profile. 7 85.7% 0.0% 14.3% 85.7% 14.3% Agreement Table 4 Final results of Area 3 - Individualised cardioversion approach to AFib in critically ill patients. Statement N. respondents % 7–9 % 4–6 % 1–3 % 4–9 % 1–6 Result 17. If there is haemodynamic instability, cardioversion is the appropriate procedure to apply. 7 100.0% 0.0% 0.0% 100.0% 0.0% Agreement 18. A “crushing” patient can be easily identified on the basis of very low blood pressure, no response to fluids, potential bradycardia, fainting, dizziness, lethargy, confusion, low urine output, cold skin, mottling. 7 100.0% 0.0% 0.0% 100.0% 0.0% Agreement 19. Unlike CCU/CICU, in Critical Care setting, up to 70% of patients can relapse after electrical cardioversion (EC). 7 85.7% 0.0% 14.3% 85.7% 14.3% Agreement 20. If EC is not effective, amiodarone may be an option in selected patients who are haemodynamically unstable or with severely impaired LVEF. 8 87.5% 12.5% 0.0% 100.0% 12.5% Agreement 21. If EC is not effective, landiolol can be an option, if not contraindicated to beta-blockade. 7 100.0% 0.0% 0.0% 100.0% 0.0% Agreement 22. If EC is not effective, landiolol can be an alternative to amiodarone, after echocardiographic exclusion of severe LV systolic dysfunction. 8 87.5% 0.0% 12.5% 87.5% 12.5% Agreement 23. Esmolol, when landiolol is not available, remains an alternative, but similarly to landiolol, it will necessitate careful titration and tight HR and BP monitoring to anticipate potential bradycardia and hypotensive effect. 8 75.0% 12.5% 12.5% 87.5% 25.0% Disagreement Table 5 Final results of Area 4 - Pharmacological approach to AFib in critically ill patients. Statement N. respondents % 7–9 % 4–6 % 1–3 % 4–9 % 1–6 Result 24. The concept of HR control or rhythm control in the critical setting has not the same significance as in cardiology setting. Indeed, in the context of new onset atrial fibrillation occurring in critical care, drugs routinely used potentially provide both rate and/or rhythm control. 7 85.7% 0.0% 14.3% 85.7% 14.3% Agreement 25. For “not crushing” patients/with no severe haemodynamic instability, HR or rhythm control should be done after or along controlling the triggers. 8 100.0% 0.0% 0.0% 100.0% 0.0% Agreement 28. Digoxin remains a feasible option unless contra-indicated (e.g. dyskalaemia, dyscalcaemia, hypoxia). 8 75.0% 12.5% 12.5% 87.5% 25.0% Disagreement 29. In absence of haemodynamic instability and in case of preexisting AFib of unknown duration which is associated with the risk of inducing a stroke, amiodarone is not an option. 7 85.7% 0.0% 14.3% 85.7% 14.3% Agreement 30. Landiolol represents an option in case of preexisting AFib of unknown duration which is associated with the risk of inducing a stroke. 8 75.0% 25.0% 0.0% 100.0% 25.0% Disagreement 31. In septic shock patients with EF below 35%, landiolol should be only used with caution in patients contra-indicated to amiodarone. 8 75.0% 12.5% 12.5% 87.5% 25.0% Disagreement 32. Non-septic patients with EF below 35% as low as 25% could be treated with landiolol. 7 85.7% 0.0% 14.3% 85.7% 14.3% Agreement 33. Landiolol should not be used in cardiogenic shock, as it is contra-indicated. 8 62.5% 37.5% 0.0% 100.0% 37.5% Disagreement Table 6 Final results of Area 5 - Titration of landiolol and HR goal to reached. Statement N. respondents % 7–9 % 4–6 % 1–3 % 4–9 % 1–6 Result 34. For starting landiolol therapy to treat AFib, dosing should be initiated as infusion without bolus, especially in crushing patients or in case of haemodynamically instability. 8 100.0% 0.0% 0.0% 100.0% 0.0% Agreement 35. Starting dose in critical care setting should be 1mcg/kg/min with a slow titration of 1mcg/kg/min step every 15–20 min. 7 100.0% 0.0% 0.0% 100.0% 0.0% Agreement 36. For patients with low cardiac output and low EF (< 35%) one should be especially careful to start with a low dose and to titrate slowly. (Increase pace of titration if needed). 7 85.7% 0.0% 14.3% 85.7% 14.3% Agreement 37. Initial HR target should be set at < 110 bpm. 7 85.7% 14.3% 0.0% 100.0% 14.3% Agreement 38. Further reduction of HR with additional titration should be done based upon individualised patient response evaluated by close haemodynamic monitoring/ECHO to assess the tolerance. 7 100.0% 0.0% 0.0% 100.0% 0.0% Agreement 39. Lowering target to < 95 bpm without advanced cardiac output monitoring is not recommended as it may harm the patient. 8 100.0% 0.0% 0.0% 100.0% 0.0% Agreement 41. In patient with haemodynamic stable condition under vasopressor, it is advised to make a test to evaluate landiolol tolerance and haemodynamic response versus expected natural course of disease. 8 87.5% 12.5% 0.0% 100.0% 12.5% Agreement Table 7 Final results of Area 6 – Duration of therapy with landiolol. Statement N. respondents % 7–9 % 4–6 % 1–3 % 4–9 % 1–6 Result 43. Landiolol infusion should not be discontinued abruptly except for resolving adverse events. 8 75.0% 12.5% 12.5% 87.5% 25.0% Disagreement 44. If rate control is obtained, landiolol should be continued until vasopressor weaning or conversion to sinus rhythm followed by conversion to oral beta blockers. 8 75.0% 12.5% 12.5% 87.5% 25.0% Disagreement Table 8 Final results of Area 7 - Therapy after stopping landiolol. Statement N. respondents % 7–9 % 4–6 % 1–3 % 4–9 % 1–6 Result 45. After stopping landiolol, the patient should be switched to an oral beta-blocker (e.g., bisoprolol) to avoid recurrence of atrial fibrillation. 7 85.7% 0.0% 14.3% 85.7% 14.3% Agreement 46. It is reasonable to rely on oral beta-blockers when enteral route is active again (e.g. patient on enteral nutrition). 7 85.7% 14.3% 0.0% 100.0% 14.3% Agreement 47. For patients with pre-existing morbid conditions (hypertension, vascular or cardiac disease, etc.) where beta-blockers are indicated beta-blockers should be initiated before ICU discharge (and discuss/refer to cardiologist). 7 100.0% 0.0% 0.0% 100.0% 0.0% Agreement 48. For patients with preexisting chronic beta-blockers, the treatment should be reinitiated as soon as possible even before the ICU discharge. 8 100.0% 0.0% 0.0% 100.0% 0.0% Agreement Table 9 Final results of Area 8 - Alternative options in case of partial success or failure with landiolol. Statement N. respondents % 7–9 % 4–6 % 1–3 % 4–9 % 1–6 Result 49. If rate control is not achieved with landiolol, intensivist can select alternative option like amiodarone or digoxin. 8 100.0% 0.0% 0.0% 100.0% 0.0% Agreement 51. Intensivist should call for cardiologist for further consultation on how to proceed in difficult patients (e.g. catheter ablation). 7 85.7% 0.0% 14.3% 85.7% 14.3% Agreement Table 10 Results of Area 9 - Landiolol and concomitant use of positive inotropic agents. Statement N. respondents % 7–9 % 4–6 % 1–3 % 4–9 % 1–6 Result 53. Before deciding to initiate an inotrope in rapid AF patient, we suggest clinicians to assess the global cardiovascular pathophysiology, with focus on coupling of ventricular to arterial elastance. 8 75.0% 0.0% 25.0% 75.0% 25.0% Disagreement 54. If inotrope support is needed in AFib patients treated with landiolol, levosimendan is suggested an option of choice because of its mechanism of action. 7 85.7% 14.3% 0.0% 100.0% 14.3% Agreement Discussion Area 1: Treatment of potential triggers of AFib in septic shock patients Strong consensus was achieved on 12 of 13 statements in this thematic area, underlining the importance of identifying and correcting reversible causes of AFib at septic shock onset (Table 2 ). This approach reflects the principle of addressing modifiable triggers prior to initiating pharmacologic HR control ( 3 , 25 – 27 ). Correction of hypovolemia and electrolyte imbalances (hypokalaemia, hypomagnesemia, and hypothermia) before HR control were the most strongly endorsed statements, in agreement with the scientific literature ( 25 , 27 ). The role of temperature management has been specifically investigated in septic patients, with external cooling shown to reduce vasopressor requirements and early mortality ( 28 ). Non-electrolyte contributors such as pain, anxiety, beta-blocker withdrawal, ischemia, and endocrine disorders were also highlighted as relevant triggers. These factors should be assessed and treated early, especially when beta-blockers like landiolol are considered ( 3 , 26 , 29 , 30 ). Adjusting catecholamine therapy in stabilised patients was recommended, suggesting dose reduction or switching to non-catecholamine agents like vasopressin to lower sympathetic drive and support HR control. Catecholamines have been consistently associated with AFib onset due to adrenergic overstimulation ( 29 ). Correction of severe anaemia alongside HR control was supported by the experts ( 25 ). No consensus was reached on whether fluid overload ( 31 , 32 ) should be corrected before initiating HR control. As its management is time-consuming, experts noted that HR control and fluid removal often need to occur simultaneously, particularly when urgent stabilisation is needed. The statement was therefore excluded. Area 2: Haemodynamic assessment in septic shock patient before HR control Unanimous consensus was reached across all statements in this area, reflecting a shared clinical conviction that HR control in septic shock with NOAF should never precede an adequate assessment of haemodynamic status (Table 3 ). Rather than relying solely on basic monitoring, the experts advocated for an integrated approach that combines continuous observation of vital signs with advanced tools for evaluating cardiovascular function and tissue perfusion ( 30 , 33 ). Minimum monitoring requirements prior to initiating HR-lowering therapies were discussed in-depth during the Delphi process. In Round 1, a statement suggesting the necessity of central access was considered excessive and misaligned with routine ICU practice. Following rewording, the revised statement clarified that while central lines are not mandatory, continuous HR and blood pressure monitoring remain essential. The experts also strongly endorsed the use of advanced modalities - such as echocardiography or dynamic assessments of preload and cardiac output - especially when therapeutic decisions carry a risk of inducing hypoperfusion ( 22 ). Monitoring of peripheral tissue perfusion indicators , including serum lactate, capillary refill time, central venous oxygen saturation (ScvO₂), and veno-arterial CO₂ difference (ΔpCO₂), was recommended. These metrics are particularly valuable when HR is being reduced, serving as early warning signs of inadequate perfusion ( 34 ). Flexibility in choosing invasive or non-invasive tools was recognised as crucial, enabling clinicians to adapt their haemodynamic evaluation to the specific context, resources, and expertise available. Area 3: Individualised cardioversion approach to AFib in critically ill patients The experts expressed strong support for a stepwise and individualised approach to cardioversion in critically ill patients with AFib, particularly in the presence of haemodynamic instability or impaired cardiac function (Table 4 ). Consensus was reached on six out of seven statements, reflecting a coherent clinical vision that balances urgency with physiologic tailoring. Electrical cardioversion (EC) was widely endorsed as the intervention of choice in patients with overt signs of cardiovascular collapse. However, even in those achieving initial conversion, the high relapse rate observed in ICU settings - reported to approach 70% - prompted the experts to advocate for pharmacologic adjuncts ( 35 , 36 ), particularly in contrast with lower relapse rates in patients managed in coronary care units ( 37 ). Amiodarone , initially described as simply “an option,” was later framed more cautiously as a treatment “that may be considered in selected patients,” specifically those with haemodynamic compromise or severely reduced left ventricular ejection fraction (LVEF) ( 8 , 16 , 36 ). This more nuanced formulation received broad support in Round 2. Landiolol was acknowledged not only as a second-line agent but also as an early option for rate control when amiodarone is contraindicated or ineffective - provided that severe LV dysfunction is excluded. The final recommendation emphasised the central role of echocardiographic evaluation in guiding the safe use of beta-blockers under these conditions ( 9 , 16 , 22 , 23 , 32 ). Importantly, the experts also agreed on the appropriateness of landiolol administration following failed EC , assuming there are no contraindications to beta-blockade. This illustrates the broader consensus around combining rhythm and rate control strategies in a physiology-guided manner, with treatment tailored to real-time patient status and cardiac performance ( 9 , 30 , 32 , 34 , 36 , 38 , 39 ). One of the few points of divergence emerged about esmolol . While the revised statement positioned it as a possible alternative in scenarios where landiolol is unavailable, the experts raised concerns about the lack of head-to-head comparisons ( 40 ) and the limited body of supportive evidence. As a result, consensus was not reached, despite rewording and acknowledgement of isolated clinical experiences suggesting benefit ( 41 , 42 ). Area 4: Pharmacological approach to AFib in critically ill patients The experts reached consensus on the complexity of managing AFib in critically ill patients and the need to move beyond conventional cardiology frameworks when tailoring therapeutic decisions in the ICU ( 11 , 30 ). The treatment choices should prioritise haemodynamic stability and clinical context rather than strict therapeutic categories. The experts acknowledged that commonly used agents such as beta-blockers and amiodarone frequently exert overlapping effects. As a consequence, the experts agreed on the limited applicability of the traditional distinction between HR and rhythm control in this setting ( 9 , 29 ). The timing of pharmacological intervention was discussed in-depth. The experts agreed that rate or rhythm control could be initiated either after or concurrently with trigger correction, depending on urgency and patient condition ( 27 , 32 ). The experts agreed on avoiding amiodarone in haemodynamically stable patients with AFib of unknown duration , due to thromboembolic risk in patients who may not be anticoagulated ( 8 , 43 ). Additionally, clinical experience supported the use of landiolol in non-septic patients with reduced ejection fraction - even below 35% - when close monitoring is ensured ( 21 , 44 – 46 ). The role of digoxin , although reworded to limit its use to carefully selected patients (e.g., absence of hypoxia or electrolyte imbalance), remained controversial. Concerns centred on its reduced efficacy in high adrenergic states typical of septic shock, where beta-blockers may offer superior rate control ( 12 , 14 ). Consensus was not reached on the use of landiolol in preexisting AFib of unknown duration . Landiolol’s primary action is rate control rather than rhythm conversion ( 9 , 20 ); yet questions were raised about its appropriateness in patients at unclear thromboembolic risk, and consensus could not be achieved despite statement revision. Concerning the landiolol use in patients with septic shock and EF < 35% who also had contraindications to amiodarone , the experts remained unconvinced given the paucity of evidence in this fragile subgroup ( 3 , 11 , 17 ). The recommendation against the use of landiolol in patients with cardiogenic or hypodynamic shock did not reach agreement due to the differing views on how to classify shock states that overlap with sepsis and the potential for low dose landiolol use in selected cases ( 9 , 47 ). Two statements - proposing the use of amiodarone or landiolol in patients with “not too severe” haemodynamic instability - were excluded after Round 1. These eliminations illustrate the challenges of defining intermediate haemodynamic conditions and the ongoing need for more granular criteria to support pharmacologic decision-making in septic AFib ( 16 , 23 , 48 , 49 ). Area 5: Titration of landiolol and HR goal to reached In this area, consensus was reached on seven statements, shaping a coherent and clinically pragmatic approach to landiolol titration and HR targets in critically ill patients with AFib (Table 6 ). The experts favoured a cautious, patient-centred strategy that balances efficacy with safety, especially in the context of haemodynamic instability ( 25 , 30 ). A central theme was the importance of initiating landiolol without a bolus , particularly in quickly deteriorating (“crashing”) patients or those with unstable haemodynamic ( 30 ), with an explicit recommendation to administer a continuous infusion only through a dedicated intravenous line, addressing safety concerns and achieving consensus in Round 2. Starting doses and titration speed were addressed. A dose of 1 mcg/kg/min with incremental increases of the same amount every 15–20 minutes was unanimously accepted, reflecting common practice and offering a balance between therapeutic effect and cardiovascular tolerance ( 49 ). This principle was reinforced in the management of patients with low cardiac output and severely reduced ejection fraction (EF < 35%), for whom the need for even more gradual escalation was emphasised ( 9 ). Regarding therapeutic targets , the experts broadly endorsed an initial HR goal below 110 bpm - consistent with general AFib management strategies ( 49 ) - but acknowledged that this may require adjustment based on clinical context, guided by careful haemodynamic monitoring, including echocardiographic assessment ( 9 , 25 ). The experts agreed to use a “test dose” as a cautious method to assess tolerability before proceeding to full titration ( 30 ). Area 6: Duration of therapy with landiolol No statements in this area reached consensus, reflecting uncertainty regarding the optimal duration and discontinuation strategies for landiolol in critically ill patients with AFib (Table 7 ). The experts failed to endorse a clear position on whether landiolol discontinuation should follow a specific protocol , especially given landiolol’s short half-life and the lack of evidence for rebound tachyarrhythmia in this context ( 50 ). Similarly, the recommendation to continue landiolol for a fixed duration of 2–3 days after rate control , was criticised as overly prescriptive. The heterogeneity of ICU patient trajectories and the absence of shared benchmarks made it difficult to define a standard tapering strategy applicable across clinical scenarios ( 17 , 50 ). These eliminations underscore the lack of consolidated practice and evidence on how to safely de-escalate beta-blockade with landiolol once HR control is achieved. They point to a broader need for prospective studies or real-world data to guide individualised discontinuation protocols in the ICU setting ( 49 ). Area 7: Therapy after stopping landiolol This area achieved full consensus across all statements (Table 8 ). The experts emphasised the importance of continuity of care, timely transition to oral therapy, and integration with long-term cardiovascular management. Agreement was reached concerning the initiation or reintroduction of oral beta-blockers to reduce the risk of AFib recurrence following ICU stabilization. Bisoprolol and similar agents were considered appropriate for this purpose, in line with existing guideline recommendations. Oral beta-blockers should be resumed once the enteral route is available, reflecting standard ICU-to-ward handover practices. Beta-blockers were considered necessary in patients with underlying cardiovascular comorbidities . The experts supported their introduction before ICU discharge, coupled with cardiology consultation. This aligns with prior evidence showing that early continuation or reintroduction of beta-blockers in acutely ill patients with cardiovascular disease is associated with improved survival ( 51 ). Particular attention was given to patients who were already on chronic beta-blocker therapy prior to ICU admission . The experts emphasised the early reinitiation of beta-blockers without implying absolute continuity. This to be better aligned with real-world practice. Observational data have shown that transitioning from intravenous beta-blockers such as landiolol to long-term oral agents is feasible and safe in patients with comorbid heart failure and AFib, provided appropriate monitoring is ensured ( 52 ). Area 8: Alternative option in case of partial success or failure with landiolol When landiolol fails to adequately control HR in critically ill patients with AFib, treatment decisions become more nuanced. The experts agreed on the recommendation to consider alternative agents such as amiodarone or digoxin , without necessarily exclude the presence of a thrombus. This pragmatic approach aligned with routine ICU practice where pharmacologic sequences are often individualised based on real-time clinical evolution ( 8 , 9 , 29 , 50 ). Cardiology consultation was also strongly endorsed, particularly in complex or refractory cases ( 9 , 30 , 43 ). The recommendation to use amiodarone (alone or in combination with EC) as a preferred option in patients with high adrenergic tone or systemic inflammation , did not reach consensus. The heterogeneity of AFib duration, thromboembolic risk, and individual response to amiodarone led many to view such a generalised recommendation as inappropriate ( 52 ). The importance of avoiding rigid algorithms was clear, with preference given to adaptable pharmacologic strategies and the integration of cardiology expertise for non-standard or high-risk scenarios. Area 9: Landiolol and concomitant use of positive inotropic agents This area explored a particularly delicate clinical scenario: the co-administration of landiolol with inotropic agents in patients requiring both HR control and inotropic support. The experts expressed clear and unanimous support for the use of levosimendan as the preferred inotrope when combined with landiolol . Its calcium-sensitizing mechanism, which enhances contractility without activating adrenergic pathways, was viewed as especially advantageous in patients with tachyarrhythmias. Unlike agents that increase intracellular cAMP, levosimendan was seen as compatible with beta-blockade, reducing the risk of counteracting the effects of landiolol or exacerbating arrhythmias ( 22 , 34 , 53 ). The experts did not reach agreement on the proposition to tailor inotrope use based on ventricular–arterial coupling . The recommendation to use phosphodiesterase III inhibitors like milrinone in combination with landiolol when hypotension is controlled , was excluded. The experts raised concerns about the potential for vasodilation and hypotensive episodes, particularly in vasoplegic patients already receiving high-dose vasopressors. The limited evidence supporting this combination ( 54 ) further undermined its acceptability in routine critical care practice. Taken together, the discussion in this area reinforces a cautious and individualised approach to combining inotropes with beta-blockade. Further research is needed to clarify the safety and efficacy of dual strategies for patients requiring simultaneous chronotropic and inotropic modulation ( 53 ). Strengths and limitations This consensus study has several strengths. It applied a structured Delphi methodology based on the RAND/UCLA framework, ensuring methodological rigour and transparency. The involvement of a multidisciplinary group of European experts with hands-on experience in both intensive care and arrhythmia management added clinical relevance. The detailed documentation of revisions further support the robustness and interpretability of the process. However, some limitations must be acknowledged. As with all consensus approaches, findings reflect expert opinion and may be influenced by individual practice patterns or therapy availability. The relatively small number of participating experts may limit the breadth of perspectives. Recommendations also rely partly on indirect evidence, as no randomised trials have specifically evaluated landiolol in septic shock. Implementation may be challenging in settings without access to advanced monitoring or cardiology support. Conclusions In this consensus, the Board issues practical, physiology-driven recommendations for the management of NOAF in patients with septic shock, a clinical scenario characterised by high complexity and limited guidance in current international guidelines. By integrating multidisciplinary expertise from critical care, cardiology, and anaesthesiology, the Board endorsed 39 statements across nine key thematic areas, offering clinicians a structured and pragmatic framework to support decision-making in real-world settings. The added value of this consensus lies in its focus on individualised rate control strategies - particularly with the use of ultra-short-acting β1-blockers such as landiolol - and on the integration of haemodynamic assessment, trigger correction, and therapeutic sequencing. The Board agreed that HR control should be considered part of a broader, physiology-driven strategy rather than a stand-alone intervention, aimed at optimizing perfusion, preventing deterioration, and tailoring care to individual patient profiles ( 8 , 9 ). Importantly, the Board highlighted timely transition to oral beta-blockers and integration with long-term cardiovascular care, including cardiology follow-up, to maintain rhythm stability and reduce AFib recurrence after ICU discharge. Some areas of uncertainty also surfaced. These uncertainties, along with the scarcity of data on safety and long-term outcomes of beta-blocker use in septic shock, warrant further investigation through prospective trials and real-world studies. Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Availability of data and materials Data sharing is not applicable to this article as no datasets were generated or analysed. Competing interests FG reported support from AOP Health related to the present manuscript; honoraria for lectures from AOP Health, Baxter, Chiesi, Edwards, Masimo, Orion, OrphaSwisse, and Viatris; participation on a Data Safety Monitoring Board or Advisory Board for AOP Health, Orion and Viatris. BL reported honoraria for lectures and support for attending meetings and/or travel from AOP Health. MB reported honoraria for lectures and participation on a Data Safety Monitoring Board or Advisory Board for AOP Health. MF reported support related to the present manuscript, honoraria for lectures and payment for expert testimony from AOP Health; participation on a Data Safety Monitoring Board or Advisory Board for AOP Health. MJ received research grants by Baxter and Fresenius. He also received consulting fees from AmPharma, Baxter, Biomerieux, Novartis and Sphingotec and honoraria for lectures from AOP Health, Baxter, Biomerieux and Vantive. DM declares no competing interests. SR received support related to the present manuscript, consulting fees, honoraria for lectures and support for attending meetings and/pr travel from AOP Health. He also received honoraria for lectures from CSL Behring. MS received support for the present manuscript, grants or contracts, consulting fees, honoraria for lectures, support for attending meetings and/or travel from AOP Health. He also participated on an Advisory Board for AOP Health and received drugs from AOP Health. Funding The Delphi consensus process and the preparation of this manuscript were supported by an unrestricted grant from AOP ORPHAN PHARMACEUTICALS GmbH - Member of the AOP Health Group. Authors’ contributions All Authors contributed to the development of the statements discussed in the Delphi process. They participated in data analysis, contributed to the conceptualization and drafting of the manuscript. All Authors have read and agreed to the published version of the manuscript. Acknowledgements We would like to thank Dr. Alessandro Urbani, the independent methodologist, for his active effort in this study. Medical writing and editorial support were provided by AKROS Bioscience S.r.l. (Pomezia, Rome, Italy). References Vélez-Gimón M. Atrial fibrillation during septic shock. Infections Sepsis Dev. 2021;359. 10.5772/intechopen.100317 . Vindhyal MR, Vasudeva R, Pothuru S, Ablah E, Choi W, Kallail K, et al. 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A prospective observational survey on landiolol in atrial fibrillation/atrial flutter patients with chronic heart failure - AF-CHF landiolol survey. J Cardiol. 2019;74(5):418–25. 10.1016/j.jjcc.2019.05.012 . Dabrowski W, Siwicka-Gieroba D, Piasek E, Schlegel TT, Jaroszynski A. Successful Combination of Landiolol and Levosimendan in Patients with Decompensated Heart Failure. Int Heart J. 2020;61(2):384–9. 10.1536/ihj.19-420 . Kobayashi S, Susa T, Tanaka T, Murakami W, Fukuta S, Okuda S, et al. Low-dose β blocker in combination with milrinone safely improves cardiac function and eliminates pulsus alternans in patients with acute decompensated heart failure. Circ J. 2012;76(7):1646–53. 10.1253/circj.cj-12-0033 . Additional Declarations Competing interest reported. FG reported support from AOP Health related to the present manuscript; honoraria for lectures from AOP Health, Baxter, Chiesi, Edwards, Masimo, Orion, OrphaSwisse, and Viatris; participation on a Data Safety Monitoring Board or Advisory Board for AOP Health, Orion and Viatris. BL reported honoraria for lectures and support for attending meetings and/or travel from AOP Health. MB reported honoraria for lectures and participation on a Data Safety Monitoring Board or Advisory Board for AOP Health. MF reported support related to the present manuscript, honoraria for lectures and payment for expert testimony from AOP Health; participation on a Data Safety Monitoring Board or Advisory Board for AOP Health. MJ received research grants by Baxter and Fresenius. He also received consulting fees from AmPharma, Baxter, Biomerieux, Novartis and Sphingotec and honoraria for lectures from AOP Health, Baxter, Biomerieux and Vantive. DM declares no competing interests. SR received support related to the present manuscript, consulting fees, honoraria for lectures and support for attending meetings and/pr travel from AOP Health. He also received honoraria for lectures from CSL Behring. MS received support for the present manuscript, grants or contracts, consulting fees, honoraria for lectures, support for attending meetings and/or travel from AOP Health. He also participated on an Advisory Board for AOP Health and received drugs from AOP Health. 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Limburg","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Fries","suffix":""},{"id":617739718,"identity":"0203641a-1bbb-4f2b-9510-b67d2000d65c","order_by":4,"name":"Michael Joannidis","email":"","orcid":"","institution":"Innsbruck Medical University","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Joannidis","suffix":""},{"id":617739719,"identity":"3b1cd51d-5a3e-4494-80e7-b5d26d3510fa","order_by":5,"name":"Demosthenes Makris","email":"","orcid":"","institution":"University of Thessaly","correspondingAuthor":false,"prefix":"","firstName":"Demosthenes","middleName":"","lastName":"Makris","suffix":""},{"id":617739720,"identity":"61d54efa-b4bd-47b6-991d-1b6e43e9e1eb","order_by":6,"name":"Sebastian Rehberg","email":"","orcid":"","institution":"Bielefeld University","correspondingAuthor":false,"prefix":"","firstName":"Sebastian","middleName":"","lastName":"Rehberg","suffix":""},{"id":617739721,"identity":"03542011-f6df-46fd-b5a5-d69d2434ac5b","order_by":7,"name":"Michel Slama","email":"","orcid":"","institution":"Centre Hospitalier Universitaire Amiens-Picardie","correspondingAuthor":false,"prefix":"","firstName":"Michel","middleName":"","lastName":"Slama","suffix":""}],"badges":[],"createdAt":"2026-03-30 16:28:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9269792/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9269792/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106540569,"identity":"15fff6ea-8559-484e-b8dd-1fb8986c354e","added_by":"auto","created_at":"2026-04-09 16:01:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":85882,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOverview of the Delphi consensus process.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9269792/v1/77cea7748eb9fd93bac1c823.png"},{"id":106728411,"identity":"e668fd74-3c53-409a-a32b-5492649f5774","added_by":"auto","created_at":"2026-04-12 18:42:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2375899,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9269792/v1/83de1a23-460d-4a69-b332-26ed4e1e98b0.pdf"},{"id":106540570,"identity":"338d66ff-02d8-4ba1-a9c4-e8a0aa4c7ca3","added_by":"auto","created_at":"2026-04-09 16:01:21","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":13943,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryInformationlegends.docx","url":"https://assets-eu.researchsquare.com/files/rs-9269792/v1/c5751bb29799df2ec9d447c4.docx"},{"id":106726885,"identity":"f71ff718-a845-41c4-877d-573838377696","added_by":"auto","created_at":"2026-04-12 18:37:30","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":29099,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-9269792/v1/ce572a19ede12f30f83919ad.docx"},{"id":106540571,"identity":"9650e214-3612-4b51-aef8-0d38987026e1","added_by":"auto","created_at":"2026-04-09 16:01:21","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":29046,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable2.docx","url":"https://assets-eu.researchsquare.com/files/rs-9269792/v1/3f8723334bbcd480a6a4716b.docx"},{"id":106540572,"identity":"ecfac98f-ac98-4c11-a35a-b8575ca13e5c","added_by":"auto","created_at":"2026-04-09 16:01:21","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":63730,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable3.docx","url":"https://assets-eu.researchsquare.com/files/rs-9269792/v1/38ab69077eecbd77e2b5679f.docx"},{"id":106725705,"identity":"d9f70c9f-838e-47e3-918f-caf1a9e9357f","added_by":"auto","created_at":"2026-04-12 18:33:32","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":48963,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable4.docx","url":"https://assets-eu.researchsquare.com/files/rs-9269792/v1/3a1e05e0caf4307c91e9f0ac.docx"}],"financialInterests":"Competing interest reported. FG reported support from AOP Health related to the present manuscript; honoraria for lectures from AOP Health, Baxter, Chiesi, Edwards, Masimo, Orion, OrphaSwisse, and Viatris; participation on a Data Safety Monitoring Board or Advisory Board for AOP Health, Orion and Viatris. \nBL reported honoraria for lectures and support for attending meetings and/or travel from AOP Health.\nMB reported honoraria for lectures and participation on a Data Safety Monitoring Board or Advisory Board for AOP Health.\nMF reported support related to the present manuscript, honoraria for lectures and payment for expert testimony from AOP Health; participation on a Data Safety Monitoring Board or Advisory Board for AOP Health.\nMJ received research grants by Baxter and Fresenius. He also received consulting fees from AmPharma, Baxter, Biomerieux, Novartis and Sphingotec and honoraria for lectures from AOP Health, Baxter, Biomerieux and Vantive.\nDM declares no competing interests.\nSR received support related to the present manuscript, consulting fees, honoraria for lectures and support for attending meetings and/pr travel from AOP Health. He also received honoraria for lectures from CSL Behring.\nMS received support for the present manuscript, grants or contracts, consulting fees, honoraria for lectures, support for attending meetings and/or travel from AOP Health. He also participated on an Advisory Board for AOP Health and received drugs from AOP Health.","formattedTitle":"Use of landiolol in septic shock patients with new onset of atrial fibrillation: A European Delphi Consensus","fulltext":[{"header":"Background","content":"\u003cp\u003eAtrial fibrillation (AFib) and septic shock frequently intersect in the intensive care setting, posing major challenges for both management and prognosis. Systemic inflammation is a key driver of new-onset AFib (NOAF), which occurs in approximately 25\u0026ndash;30% of patients with septic shock (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The haemodynamic instability resulting from inflammation increases the risk of AFib and may exacerbate cardiac dysfunction and organ failure (\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Patients developing NOAF during septic shock tend to have worse outcomes, including prolonged intensive care unit (ICU) stay and higher mortality (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile the 2020 and 2024 ESC Guidelines define AFib management as a comprehensive strategy encompassing stroke prevention, rate and rhythm control, and risk factor modification (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), this paradigm shifts in critically ill patients. In ICU patients with NOAF, rhythm control is often prioritised, although treatment decisions should be individualised and guided by haemodynamic status and bedside echocardiographic assessment (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNonetheless, the pharmacological agents commonly recommended for heart rate (HR) control - such as beta-blockers, non-dihydropyridine calcium-channel blockers, and digoxin - may be poorly tolerated in this population due to frequent haemodynamic compromise, including hypotension and ventricular dysfunction (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Among commonly used beta-blockers, including metoprolol and esmolol, landiolol combines high β1-selectivity with a rapid-acting and short-lasting pharmacokinetic profile (Supplementary Table\u0026nbsp;1 and Paragraph \u0026ldquo;Pharmacological profile of landiolol\u0026rdquo;). These features may help limit hypotensive and off-target organ effects while allowing better titratability and reversibility of adverse effects (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLandiolol has been associated with good tolerability and faster HR control when compared to digoxin, for treatment patients in acute heart failure with AFib (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the setting of septic shock, landiolol has been shown to effectively control HR without increasing vasopressor requirements, while supporting the restoration of sinus rhythm and improving organ perfusion (\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Evidence also suggests that landiolol may mitigate catecholamine-induced inflammation and improve metabolic homeostasis (\u003cspan additionalcitationids=\"CR20 CR21 CR22\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCurrent ESC guidelines do not provide specific recommendations for the management of Afib in patients with septic shock or for the use of ultra-short-acting beta-blockers such as landiolol in this setting (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). This lack of guidance contributes to marked heterogeneity in clinical practice, particularly among clinicians less familiar with the management of NOAF in critically ill patients. During an Advisory Board held in Vienna on 6 May 2024, experts agreed that a Delphi consensus process would be the most appropriate approach to reduce this variability and provide practical, experience-based recommendations. As a result, a multidisciplinary group of European experts in anaesthesiology, intensive care, and cardiology was convened to develop a RAND/UCLA Delphi consensus-based guidance on the safe and effective use of landiolol in septic patients with NOAF. The scope was limited to AFib in septic shock, excluding cases with sinus tachycardia (e.g., STRESS-L population), and all recommendations were designed to align with international AFib guidelines (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The guidance was intentionally conservative, avoiding complex interventions reserved for expert centres.\u003c/p\u003e\n\u003ch3\u003ePharmacological profile of landiolol\u003c/h3\u003e\n\u003cp\u003eLandiolol is an aryloxypropanolamine beta-blocker characterised by very high \u0026beta;1-selectivity (\u0026beta;1/\u0026beta;2 \u0026asymp; 250) and an ultra-short duration of action, with a plasma half-life of 3-4 minutes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt is rapidly hydrolysed by plasma pseudocholinesterases and administered via continuous intravenous infusion, allowing for tight titration and prompt discontinuation if needed (13, 24). These pharmacokinetic properties translate into a rapid onset and offset of action, contributing to good haemodynamic tolerability - even in patients with left ventricular dysfunction or on vasopressors.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis project was conducted following a structured process based on a modified RAND/UCLA Delphi methodology.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eBoard\u003c/h3\u003e\n\u003cp\u003eA Scientific Board composed of nine experts in anaesthesiology, intensive care, and cardiology - each with recognised experience in the management of AFib and critically ill patients - was convened to support the development of the consensus. The members were selected to ensure a multidisciplinary perspective and broad geographical representation across Europe. Supplementary Table\u0026nbsp;2 displays the list of the members of the Scientific Board.\u003c/p\u003e \u003cp\u003eTwo of the members of the Scientific Board (Prof. Fabio Guarracino and Michel Slama) chaired the initiative and constituted the Editorial Board, responsible for defining the scientific criteria, identifying the thematic areas to be explored, and conducting the literature search necessary for the development of the Delphi questionnaire.\u003c/p\u003e \u003cp\u003eThe Scientific Board reviewed the selected topics and contributed to the formulation of consensus statements. An independent methodologist (Dr. Alessandro Urbani), with expertise in systematic reviews, meta-analyses, and the Delphi method, participated in both Boards.\u003c/p\u003e\n\u003ch3\u003eDelphi questionnaire definition and Delphi poll\u003c/h3\u003e\n\u003cp\u003eA comprehensive literature search and review was conducted by the Editorial Board.\u003c/p\u003e \u003cp\u003eBased on the literature review, the questionnaire was validated during the first meeting of the Scientific Board and comprised 55 initial statements across nine thematic areas (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of statements across thematic areas.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThematic area\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of statements\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Treatment of potential triggers of AFib in septic shock patient.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Haemodynamic assessment in septic shock patient before HR control.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Individualised cardioversion approach to AFib in critically ill patients.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Pharmacological approach to AFib in critically ill patients.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Titration of landiolol and HR goal to reached.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Duration of therapy with landiolol.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. Therapy after stopping landiolol.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. Alternative option in case of partial success or failure with landiolol.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. Landiolol and concomitant use of positive inotropic agents.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe Delphi poll was discussed in two Rounds (web meetings in March and June 2025). Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e displays the structure of the project.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe Board rated their level of agreement with each statement using a 9-point Likert scale (1\u0026thinsp;=\u0026thinsp;maximum disagreement; 9\u0026thinsp;=\u0026thinsp;maximum agreement).\u003c/p\u003e \u003cp\u003eAgreement was defined as \u0026ge;\u0026thinsp;80% of responses falling within the same three-point region (1\u0026ndash;3, 4\u0026ndash;6, or 7\u0026ndash;9). Disagreement was defined as \u0026ge;\u0026thinsp;85% of responses distributed across the two wide regions (1\u0026ndash;6 or 4\u0026ndash;9). Statements that did not meet the agreement criterion were subjected to elimination or rewording. In Round 1, statements that reached agreement were retained without modifications.\u003c/p\u003e \u003cp\u003eIn Round 2 clinical experts re-evaluated the statements that did not reach consensus in Round 1.\u003c/p\u003e \u003cp\u003eThe methodologist analysed and summarised the results while keeping the individual ratings anonymous.\u003c/p\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003eThis Delphi study did not involve human participants, patients, or personal health data. Therefore, in accordance with applicable ethical standards and institutional policies, formal approval by an Ethics Committee was not required. All experts participated voluntarily and anonymously in the consensus process.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe Scientific Board evaluated the 55 statements through two Delphi Rounds.\u003c/p\u003e \u003cp\u003eIn Round 1, agreement was reached on 23 statements (41.8%). Of the remaining 32 statements, 7 (12.7%) were excluded due to lack of consensus, while 25 (45.5%) were revised and carried forward to Round 2 (Supplementary Table\u0026nbsp;3).\u003c/p\u003e \u003cp\u003eIn Round 2, consensus was achieved for 16 out of 25 remaining statements, while 9 did not reach consensus (Supplementary Table\u0026nbsp;4).\u003c/p\u003e \u003cp\u003eOverall, 39 of the 55 statements (70.9%) were included in the final recommendations, and 16 (29.1%) were excluded across the two Rounds.\u003c/p\u003e \u003cp\u003eResults are presented below by thematic area. For each area, tables report statements reaching agreement and those classified as disagreement but retained. Supplementary Tables\u0026nbsp;3 and 4 provide the complete list of statements and outcomes across both Rounds.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTreatment of potential triggers of AFib in septic shock patient (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e): The agreement was reached on 12 out of 13 statements;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHaemodynamic assessment in septic shock patient before HR control (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e): full consensus across all three statements;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIndividualised cardioversion approach to AFib in critically ill patients (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e): The experts agreed on 6 of 7 statements, with one statement remaining in disagreement;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePharmacological approach to AFib in critically ill patients (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e): Four of 10 statements were agreed upon, while 6 did not reach consensus;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTitration of landiolol and HR goal to reached (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e): Area 5 saw agreement with 7 out of 9 statements achieving consensus;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDuration of therapy with landiolol (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e): Area 6 did not reach agreement on its two statements, despite attempts to reword them;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTherapy after stopping landiolol (Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e): Consensus was achieved with all 4 statements;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAlternative option in case of partial success or failure with landiolol (Table\u0026nbsp;\u003cspan refid=\"Tab9\" class=\"InternalRef\"\u003e9\u003c/span\u003e): Consensus was reached on 2 of 4 statements;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLandiolol and concomitant use of positive inotropic agents (Table\u0026nbsp;\u003cspan refid=\"Tab10\" class=\"InternalRef\"\u003e10\u003c/span\u003e): Only 1 of 3 statements accepted.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFinal results of Area 1 - Treatment of potential triggers of AFib in septic shock patient.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStatement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN. respondents\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e% 7\u0026ndash;9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e% 4\u0026ndash;6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e% 1\u0026ndash;3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e% 4\u0026ndash;9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e% 1\u0026ndash;6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eResult\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. At first presentation of septic shock patient, is key important to identify all triggers of AFib before starting any treatments to control HR.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. At first presentation of septic shock patient, hypovolemia should be identified and corrected before starting controlling HR.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. At first presentation of septic shock patient, withdrawal of beta-blockers should be identified as potential trigger.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. At first presentation of septic shock patient with AFib, pain or anxiety (e.g. postoperative) should be detected before starting controlling HR.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e87.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. At first presentation of septic shock patient, hypokalaemia should be identified and corrected before starting controlling HR.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. At first presentation of septic shock patient with AFib, suspected hypomagnesemia may be identified and corrected before starting controlling HR with landiolol, but without delaying in case of haemodynamic instability.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e87.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. In case of AFib in stabilised septic shock patient, doses of catecholamine (vasopressors, inotrope) should be revaluated and non-catecholamine vasopressors (e.g. vasopressin) may be considered as it allows to decrease catecholamine doses and HR along with contemplating starting controlling HR.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. At first presentation of septic shock patient with AFib, high fever should be detected and could be treated before starting controlling HR but without delaying in case of haemodynamic instability.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. At first presentation of septic shock patient with AFib, severe anaemia and in absence of hypovolemia should be identified, and its management should be initiated along with starting controlling HR, and without delay in case of haemodynamic instability.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11. At first presentation of septic shock patient with AFib, myocardial ischemia should be detected and treated, but HR control should not be delayed as tachycardia contributes to increase DO2/VO2 imbalance and induce further critical ischemia.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12. Endocrine disorders (pheochromocytoma or elevated thyroid hormones) should be investigated in the context of HR control as a potential trigger to further adjust patient management.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13. At first presentation of septic shock patient, severe hypothermia should be identified and corrected before starting controlling HR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFinal results of Area 2 - Haemodynamic assessment in septic shock patient before HR control.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStatement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN. respondents\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e% 7\u0026ndash;9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e% 4\u0026ndash;6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e% 1\u0026ndash;3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e% 4\u0026ndash;9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e% 1\u0026ndash;6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eResult\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14. Determination of haemodynamic parameters with continuous HR and BP and is the minimum requirement to control patient response/condition, and advanced monitoring for cardiac assessment is recommended.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15. Clinical monitoring of tissue perfusion is important when reducing HR rate (the more HR is reduced the tighter the control of tissue perfusion has to be checked: lactate, capillary refill time test, ScvO2 and /or Delta pCO2).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16. Invasive and/or non-invasive tools can be used to assess haemodynamic profile.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFinal results of Area 3 - Individualised cardioversion approach to AFib in critically ill patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStatement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN. respondents\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e% 7\u0026ndash;9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e% 4\u0026ndash;6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e% 1\u0026ndash;3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e% 4\u0026ndash;9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e% 1\u0026ndash;6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eResult\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17. If there is haemodynamic instability, cardioversion is the appropriate procedure to apply.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18. A \u0026ldquo;crushing\u0026rdquo; patient can be easily identified on the basis of very low blood pressure, no response to fluids, potential bradycardia, fainting, dizziness, lethargy, confusion, low urine output, cold skin, mottling.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19. Unlike CCU/CICU, in Critical Care setting, up to 70% of patients can relapse after electrical cardioversion (EC).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20. If EC is not effective, amiodarone may be an option in selected patients who are haemodynamically unstable or with severely impaired LVEF.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21. If EC is not effective, landiolol can be an option, if not contraindicated to beta-blockade.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22. If EC is not effective, landiolol can be an alternative to amiodarone, after echocardiographic exclusion of severe LV systolic dysfunction.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e87.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23. Esmolol, when landiolol is not available, remains an alternative, but similarly to landiolol, it will necessitate careful titration and tight HR and BP monitoring to anticipate potential bradycardia and hypotensive effect.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e87.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e25.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDisagreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFinal results of Area 4 - Pharmacological approach to AFib in critically ill patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStatement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN. respondents\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e% 7\u0026ndash;9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e% 4\u0026ndash;6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e% 1\u0026ndash;3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e% 4\u0026ndash;9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e% 1\u0026ndash;6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eResult\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24. The concept of HR control or rhythm control in the critical setting has not the same significance as in cardiology setting. Indeed, in the context of new onset atrial fibrillation occurring in critical care, drugs routinely used potentially provide both rate and/or rhythm control.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25. For \u0026ldquo;not crushing\u0026rdquo; patients/with no severe haemodynamic instability, HR or rhythm control should be done after or along controlling the triggers.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e28. Digoxin remains a feasible option unless contra-indicated (e.g. dyskalaemia, dyscalcaemia, hypoxia).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e87.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e25.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDisagreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e29. In absence of haemodynamic instability and in case of preexisting AFib of unknown duration which is associated with the risk of inducing a stroke, amiodarone is not an option.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30. Landiolol represents an option in case of preexisting AFib of unknown duration which is associated with the risk of inducing a stroke.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e25.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDisagreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31. In septic shock patients with EF below 35%, landiolol should be only used with caution in patients contra-indicated to amiodarone.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e87.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e25.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDisagreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e32. Non-septic patients with EF below 35% as low as 25% could be treated with landiolol.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e33. Landiolol should not be used in cardiogenic shock, as it is contra-indicated.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e37.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDisagreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFinal results of Area 5 - Titration of landiolol and HR goal to reached.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStatement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN. respondents\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e% 7\u0026ndash;9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e% 4\u0026ndash;6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e% 1\u0026ndash;3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e% 4\u0026ndash;9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e% 1\u0026ndash;6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eResult\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e34. For starting landiolol therapy to treat AFib, dosing should be initiated as infusion without bolus, especially in crushing patients or in case of haemodynamically instability.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35. Starting dose in critical care setting should be 1mcg/kg/min with a slow titration of 1mcg/kg/min step every 15\u0026ndash;20 min.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36. For patients with low cardiac output and low EF (\u0026lt;\u0026thinsp;35%) one should be especially careful to start with a low dose and to titrate slowly. (Increase pace of titration if needed).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e37. Initial HR target should be set at \u0026lt;\u0026thinsp;110 bpm.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e38. Further reduction of HR with additional titration should be done based upon individualised patient response evaluated by close haemodynamic monitoring/ECHO to assess the tolerance.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e39. Lowering target to \u0026lt;\u0026thinsp;95 bpm without advanced cardiac output monitoring is not recommended as it may harm the patient.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e41. In patient with haemodynamic stable condition under vasopressor, it is advised to make a test to evaluate landiolol tolerance and haemodynamic response versus expected natural course of disease.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFinal results of Area 6 \u0026ndash; Duration of therapy with landiolol.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStatement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN. respondents\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e% 7\u0026ndash;9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e% 4\u0026ndash;6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e% 1\u0026ndash;3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e% 4\u0026ndash;9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e% 1\u0026ndash;6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eResult\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e43. Landiolol infusion should not be discontinued abruptly except for resolving adverse events.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e87.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e25.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDisagreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e44. If rate control is obtained, landiolol should be continued until vasopressor weaning or conversion to sinus rhythm followed by conversion to oral beta blockers.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e87.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e25.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDisagreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFinal results of Area 7 - Therapy after stopping landiolol.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStatement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN. respondents\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e% 7\u0026ndash;9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e% 4\u0026ndash;6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e% 1\u0026ndash;3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e% 4\u0026ndash;9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e% 1\u0026ndash;6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eResult\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e45. After stopping landiolol, the patient should be switched to an oral beta-blocker (e.g., bisoprolol) to avoid recurrence of atrial fibrillation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e46. It is reasonable to rely on oral beta-blockers when enteral route is active again (e.g. patient on enteral nutrition).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e47. For patients with pre-existing morbid conditions (hypertension, vascular or cardiac disease, etc.) where beta-blockers are indicated beta-blockers should be initiated before ICU discharge (and discuss/refer to cardiologist).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e48. For patients with preexisting chronic beta-blockers, the treatment should be reinitiated as soon as possible even before the ICU discharge.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab9\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 9\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFinal results of Area 8 - Alternative options in case of partial success or failure with landiolol.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStatement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN. respondents\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e% 7\u0026ndash;9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e% 4\u0026ndash;6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e% 1\u0026ndash;3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e% 4\u0026ndash;9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e% 1\u0026ndash;6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eResult\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e49. If rate control is not achieved with landiolol, intensivist can select alternative option like amiodarone or digoxin.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e51. Intensivist should call for cardiologist for further consultation on how to proceed in difficult patients (e.g. catheter ablation).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab10\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 10\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of Area 9 - Landiolol and concomitant use of positive inotropic agents.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStatement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN. respondents\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e% 7\u0026ndash;9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e% 4\u0026ndash;6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e% 1\u0026ndash;3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e% 4\u0026ndash;9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e% 1\u0026ndash;6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eResult\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e53. Before deciding to initiate an inotrope in rapid AF patient, we suggest clinicians to assess the global cardiovascular pathophysiology, with focus on coupling of ventricular to arterial elastance.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e75.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e25.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDisagreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e54. If inotrope support is needed in AFib patients treated with landiolol, levosimendan is suggested an option of choice because of its mechanism of action.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eArea 1: Treatment of potential triggers of AFib in septic shock patients\u003c/h2\u003e \u003cp\u003eStrong consensus was achieved on 12 of 13 statements in this thematic area, underlining the importance of identifying and correcting reversible causes of AFib at septic shock onset (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This approach reflects the principle of addressing modifiable triggers prior to initiating pharmacologic HR control (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eCorrection of hypovolemia\u003c/b\u003e and electrolyte imbalances (hypokalaemia, hypomagnesemia, and hypothermia) before HR control were the most strongly endorsed statements, in agreement with the scientific literature (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The role of temperature management has been specifically investigated in septic patients, with external cooling shown to reduce vasopressor requirements and early mortality (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eNon-electrolyte contributors\u003c/b\u003e such as pain, anxiety, beta-blocker withdrawal, ischemia, and endocrine disorders were also highlighted as relevant triggers. These factors should be assessed and treated early, especially when beta-blockers like landiolol are considered (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eAdjusting catecholamine therapy\u003c/b\u003e in stabilised patients was recommended, suggesting dose reduction or switching to non-catecholamine agents like vasopressin to lower sympathetic drive and support HR control. Catecholamines have been consistently associated with AFib onset due to adrenergic overstimulation (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eCorrection of severe anaemia\u003c/b\u003e alongside HR control was supported by the experts (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNo consensus was reached on whether \u003cb\u003efluid overload\u003c/b\u003e (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) should be corrected before initiating HR control. As its management is time-consuming, experts noted that HR control and fluid removal often need to occur simultaneously, particularly when urgent stabilisation is needed. The statement was therefore excluded.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eArea 2: Haemodynamic assessment in septic shock patient before HR control\u003c/h3\u003e\n\u003cp\u003eUnanimous consensus was reached across all statements in this area, reflecting a shared clinical conviction that HR control in septic shock with NOAF should never precede an adequate assessment of haemodynamic status (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Rather than relying solely on basic monitoring, the experts advocated for an integrated approach that combines continuous observation of vital signs with advanced tools for evaluating cardiovascular function and tissue perfusion (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eMinimum monitoring requirements\u003c/b\u003e prior to initiating HR-lowering therapies were discussed in-depth during the Delphi process. In Round 1, a statement suggesting the necessity of central access was considered excessive and misaligned with routine ICU practice. Following rewording, the revised statement clarified that while central lines are not mandatory, continuous HR and blood pressure monitoring remain essential. The experts also strongly endorsed the use of advanced modalities - such as echocardiography or dynamic assessments of preload and cardiac output - especially when therapeutic decisions carry a risk of inducing hypoperfusion (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eMonitoring of peripheral tissue perfusion indicators\u003c/b\u003e, including serum lactate, capillary refill time, central venous oxygen saturation (ScvO₂), and veno-arterial CO₂ difference (ΔpCO₂), was recommended. These metrics are particularly valuable when HR is being reduced, serving as early warning signs of inadequate perfusion (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFlexibility in choosing invasive or non-invasive tools\u003c/b\u003e was recognised as crucial, enabling clinicians to adapt their haemodynamic evaluation to the specific context, resources, and expertise available.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eArea 3: Individualised cardioversion approach to AFib in critically ill patients\u003c/h2\u003e \u003cp\u003eThe experts expressed strong support for a stepwise and individualised approach to cardioversion in critically ill patients with AFib, particularly in the presence of haemodynamic instability or impaired cardiac function (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Consensus was reached on six out of seven statements, reflecting a coherent clinical vision that balances urgency with physiologic tailoring.\u003c/p\u003e \u003cp\u003e \u003cb\u003eElectrical cardioversion\u003c/b\u003e (EC) was widely endorsed as the intervention of choice in patients with overt signs of cardiovascular collapse. However, even in those achieving initial conversion, the high relapse rate observed in ICU settings - reported to approach 70% - prompted the experts to advocate for pharmacologic adjuncts (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), particularly in contrast with lower relapse rates in patients managed in coronary care units (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eAmiodarone\u003c/b\u003e, initially described as simply \u0026ldquo;an option,\u0026rdquo; was later framed more cautiously as a treatment \u0026ldquo;that may be considered in selected patients,\u0026rdquo; specifically those with haemodynamic compromise or severely reduced left ventricular ejection fraction (LVEF) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). This more nuanced formulation received broad support in Round 2.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLandiolol\u003c/b\u003e was acknowledged not only as a second-line agent but also as an early option for rate control when amiodarone is contraindicated or ineffective - provided that severe LV dysfunction is excluded. The final recommendation emphasised the central role of echocardiographic evaluation in guiding the safe use of beta-blockers under these conditions (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Importantly, the experts also agreed on the appropriateness of \u003cb\u003elandiolol administration following failed EC\u003c/b\u003e, assuming there are no contraindications to beta-blockade. This illustrates the broader consensus around combining rhythm and rate control strategies in a physiology-guided manner, with treatment tailored to real-time patient status and cardiac performance (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOne of the few points of divergence emerged about \u003cb\u003eesmolol\u003c/b\u003e. While the revised statement positioned it as a possible alternative in scenarios where landiolol is unavailable, the experts raised concerns about the lack of head-to-head comparisons (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) and the limited body of supportive evidence. As a result, consensus was not reached, despite rewording and acknowledgement of isolated clinical experiences suggesting benefit (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eArea 4: Pharmacological approach to AFib in critically ill patients\u003c/h2\u003e \u003cp\u003eThe experts reached consensus on the complexity of managing AFib in critically ill patients and the need to move beyond conventional cardiology frameworks when tailoring therapeutic decisions in the ICU (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe \u003cb\u003etreatment choices should prioritise haemodynamic stability and clinical context\u003c/b\u003e rather than strict therapeutic categories. The experts acknowledged that commonly used agents such as beta-blockers and amiodarone frequently exert overlapping effects. As a consequence, the experts agreed on the limited applicability of the traditional distinction between HR and rhythm control in this setting (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe \u003cb\u003etiming of pharmacological intervention\u003c/b\u003e was discussed in-depth. The experts agreed that rate or rhythm control could be initiated either after or concurrently with trigger correction, depending on urgency and patient condition (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe experts agreed on \u003cb\u003eavoiding amiodarone in haemodynamically stable patients with AFib of unknown duration\u003c/b\u003e, due to thromboembolic risk in patients who may not be anticoagulated (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Additionally, clinical experience supported the \u003cb\u003euse of landiolol in non-septic patients with reduced ejection fraction\u003c/b\u003e - even below 35% - when close monitoring is ensured (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR45\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe \u003cb\u003erole of digoxin\u003c/b\u003e, although reworded to limit its use to carefully selected patients (e.g., absence of hypoxia or electrolyte imbalance), remained controversial. Concerns centred on its reduced efficacy in high adrenergic states typical of septic shock, where beta-blockers may offer superior rate control (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConsensus was not reached on the \u003cb\u003euse of landiolol in preexisting AFib of unknown duration\u003c/b\u003e. Landiolol\u0026rsquo;s primary action is rate control rather than rhythm conversion (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e); yet questions were raised about its appropriateness in patients at unclear thromboembolic risk, and consensus could not be achieved despite statement revision.\u003c/p\u003e \u003cp\u003eConcerning the \u003cb\u003elandiolol use in patients with septic shock and EF\u0026thinsp;\u0026lt;\u0026thinsp;35% who also had contraindications to amiodarone\u003c/b\u003e, the experts remained unconvinced given the paucity of evidence in this fragile subgroup (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The recommendation \u003cb\u003eagainst the use of landiolol in patients with cardiogenic or hypodynamic shock\u003c/b\u003e did not reach agreement due to the differing views on how to classify shock states that overlap with sepsis and the potential for low dose landiolol use in selected cases (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTwo statements - \u003cb\u003eproposing the use of amiodarone or landiolol in patients with \u0026ldquo;not too severe\u0026rdquo; haemodynamic instability\u003c/b\u003e - were excluded after Round 1. These eliminations illustrate the challenges of defining intermediate haemodynamic conditions and the ongoing need for more granular criteria to support pharmacologic decision-making in septic AFib (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eArea 5: Titration of landiolol and HR goal to reached\u003c/h2\u003e \u003cp\u003eIn this area, consensus was reached on seven statements, shaping a coherent and clinically pragmatic approach to landiolol titration and HR targets in critically ill patients with AFib (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). The experts favoured a cautious, patient-centred strategy that balances efficacy with safety, especially in the context of haemodynamic instability (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA central theme was the importance of \u003cb\u003einitiating landiolol without a bolus\u003c/b\u003e, particularly in quickly deteriorating (\u0026ldquo;crashing\u0026rdquo;) patients or those with unstable haemodynamic (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), with an explicit recommendation to administer a continuous infusion only through a dedicated intravenous line, addressing safety concerns and achieving consensus in Round 2.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStarting doses and titration speed\u003c/b\u003e were addressed. A dose of 1 mcg/kg/min with incremental increases of the same amount every 15\u0026ndash;20 minutes was unanimously accepted, reflecting common practice and offering a balance between therapeutic effect and cardiovascular tolerance (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). This principle was reinforced in the management of patients with low cardiac output and severely reduced ejection fraction (EF\u0026thinsp;\u0026lt;\u0026thinsp;35%), for whom the need for even more gradual escalation was emphasised (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eRegarding therapeutic targets\u003c/b\u003e, the experts broadly endorsed an \u003cb\u003einitial HR goal below 110 bpm\u003c/b\u003e - consistent with general AFib management strategies (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e) - but acknowledged that this may require adjustment based on clinical context, guided by careful haemodynamic monitoring, including echocardiographic assessment (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The experts agreed to use a \u0026ldquo;test dose\u0026rdquo; as a cautious method to assess tolerability before proceeding to full titration (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eArea 6: Duration of therapy with landiolol\u003c/h2\u003e \u003cp\u003eNo statements in this area reached consensus, reflecting uncertainty regarding the optimal duration and discontinuation strategies for landiolol in critically ill patients with AFib (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe experts failed to endorse a clear position on \u003cb\u003ewhether landiolol discontinuation should follow a specific protocol\u003c/b\u003e, especially given landiolol\u0026rsquo;s short half-life and the lack of evidence for rebound tachyarrhythmia in this context (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSimilarly, the \u003cb\u003erecommendation to continue landiolol for a fixed duration of 2\u0026ndash;3 days after rate control\u003c/b\u003e, was criticised as overly prescriptive. The heterogeneity of ICU patient trajectories and the absence of shared benchmarks made it difficult to define a standard tapering strategy applicable across clinical scenarios (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThese eliminations underscore the lack of consolidated practice and evidence on how to safely de-escalate beta-blockade with landiolol once HR control is achieved. They point to a broader need for prospective studies or real-world data to guide individualised discontinuation protocols in the ICU setting (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eArea 7: Therapy after stopping landiolol\u003c/h2\u003e \u003cp\u003eThis area achieved full consensus across all statements (Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e). The experts emphasised the importance of continuity of care, timely transition to oral therapy, and integration with long-term cardiovascular management.\u003c/p\u003e \u003cp\u003eAgreement was reached concerning the \u003cb\u003einitiation or reintroduction of oral beta-blockers\u003c/b\u003e to reduce the risk of AFib recurrence following ICU stabilization. Bisoprolol and similar agents were considered appropriate for this purpose, in line with existing guideline recommendations. Oral beta-blockers should be resumed once the enteral route is available, reflecting standard ICU-to-ward handover practices.\u003c/p\u003e \u003cp\u003e \u003cb\u003eBeta-blockers\u003c/b\u003e were considered necessary \u003cb\u003ein patients with underlying cardiovascular comorbidities\u003c/b\u003e. The experts supported their introduction before ICU discharge, coupled with cardiology consultation. This aligns with prior evidence showing that early continuation or reintroduction of beta-blockers in acutely ill patients with cardiovascular disease is associated with improved survival (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eParticular attention was given to \u003cb\u003epatients who were already on chronic beta-blocker therapy prior to ICU admission\u003c/b\u003e. The experts emphasised the early reinitiation of beta-blockers without implying absolute continuity. This to be better aligned with real-world practice. Observational data have shown that transitioning from intravenous beta-blockers such as landiolol to long-term oral agents is feasible and safe in patients with comorbid heart failure and AFib, provided appropriate monitoring is ensured (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eArea 8: Alternative option in case of partial success or failure with landiolol\u003c/h2\u003e \u003cp\u003eWhen landiolol fails to adequately control HR in critically ill patients with AFib, treatment decisions become more nuanced.\u003c/p\u003e \u003cp\u003eThe experts agreed on the recommendation to \u003cb\u003econsider alternative agents such as amiodarone or digoxin\u003c/b\u003e, without necessarily exclude the presence of a thrombus. This pragmatic approach aligned with routine ICU practice where pharmacologic sequences are often individualised based on real-time clinical evolution (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eCardiology consultation\u003c/b\u003e was also strongly endorsed, particularly in complex or refractory cases (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe recommendation to \u003cb\u003euse amiodarone (alone or in combination with EC) as a preferred option in patients with high adrenergic tone or systemic inflammation\u003c/b\u003e, did not reach consensus. The heterogeneity of AFib duration, thromboembolic risk, and individual response to amiodarone led many to view such a generalised recommendation as inappropriate (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe importance of avoiding rigid algorithms was clear, with preference given to adaptable pharmacologic strategies and the integration of cardiology expertise for non-standard or high-risk scenarios.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eArea 9: Landiolol and concomitant use of positive inotropic agents\u003c/h2\u003e \u003cp\u003eThis area explored a particularly delicate clinical scenario: the co-administration of landiolol with inotropic agents in patients requiring both HR control and inotropic support.\u003c/p\u003e \u003cp\u003eThe experts expressed clear and unanimous support for the \u003cb\u003euse of levosimendan as the preferred inotrope when combined with landiolol\u003c/b\u003e. Its calcium-sensitizing mechanism, which enhances contractility without activating adrenergic pathways, was viewed as especially advantageous in patients with tachyarrhythmias. Unlike agents that increase intracellular cAMP, levosimendan was seen as compatible with beta-blockade, reducing the risk of counteracting the effects of landiolol or exacerbating arrhythmias (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe experts did not reach agreement on the \u003cb\u003eproposition to tailor inotrope use based on ventricular\u0026ndash;arterial coupling\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eThe recommendation to \u003cb\u003euse phosphodiesterase III inhibitors like milrinone in combination with landiolol when hypotension is controlled\u003c/b\u003e, was excluded. The experts raised concerns about the potential for vasodilation and hypotensive episodes, particularly in vasoplegic patients already receiving high-dose vasopressors. The limited evidence supporting this combination (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e) further undermined its acceptability in routine critical care practice.\u003c/p\u003e \u003cp\u003eTaken together, the discussion in this area reinforces a cautious and individualised approach to combining inotropes with beta-blockade. Further research is needed to clarify the safety and efficacy of dual strategies for patients requiring simultaneous chronotropic and inotropic modulation (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis consensus study has several strengths. It applied a structured Delphi methodology based on the RAND/UCLA framework, ensuring methodological rigour and transparency. The involvement of a multidisciplinary group of European experts with hands-on experience in both intensive care and arrhythmia management added clinical relevance. The detailed documentation of revisions further support the robustness and interpretability of the process.\u003c/p\u003e \u003cp\u003eHowever, some limitations must be acknowledged. As with all consensus approaches, findings reflect expert opinion and may be influenced by individual practice patterns or therapy availability. The relatively small number of participating experts may limit the breadth of perspectives. Recommendations also rely partly on indirect evidence, as no randomised trials have specifically evaluated landiolol in septic shock. Implementation may be challenging in settings without access to advanced monitoring or cardiology support.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this consensus, the Board issues practical, physiology-driven recommendations for the management of NOAF in patients with septic shock, a clinical scenario characterised by high complexity and limited guidance in current international guidelines. By integrating multidisciplinary expertise from critical care, cardiology, and anaesthesiology, the Board endorsed 39 statements across nine key thematic areas, offering clinicians a structured and pragmatic framework to support decision-making in real-world settings.\u003c/p\u003e \u003cp\u003eThe added value of this consensus lies in its focus on individualised rate control strategies - particularly with the use of ultra-short-acting β1-blockers such as landiolol - and on the integration of haemodynamic assessment, trigger correction, and therapeutic sequencing. The Board agreed that HR control should be considered part of a broader, physiology-driven strategy rather than a stand-alone intervention, aimed at optimizing perfusion, preventing deterioration, and tailoring care to individual patient profiles (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eImportantly, the Board highlighted timely transition to oral beta-blockers and integration with long-term cardiovascular care, including cardiology follow-up, to maintain rhythm stability and reduce AFib recurrence after ICU discharge. Some areas of uncertainty also surfaced. These uncertainties, along with the scarcity of data on safety and long-term outcomes of beta-blocker use in septic shock, warrant further investigation through prospective trials and real-world studies.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable to this article as no datasets were generated or analysed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFG reported support from AOP Health related to the present manuscript; honoraria for lectures from AOP Health, Baxter, Chiesi, Edwards, Masimo, Orion, OrphaSwisse, and Viatris; participation on a Data Safety Monitoring Board or Advisory Board for AOP Health, Orion and Viatris.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBL reported honoraria for lectures and support for attending meetings and/or travel from AOP Health.\u003c/p\u003e\n\u003cp\u003eMB reported honoraria for lectures and participation on a Data Safety Monitoring Board or Advisory Board for AOP Health.\u003c/p\u003e\n\u003cp\u003eMF reported support related to the present manuscript, honoraria for lectures and payment for expert testimony from AOP Health; participation on a Data Safety Monitoring Board or Advisory Board for AOP Health.\u003c/p\u003e\n\u003cp\u003eMJ received research grants by Baxter and Fresenius. He also received consulting fees from AmPharma, Baxter, Biomerieux, Novartis and Sphingotec and honoraria for lectures from AOP Health, Baxter, Biomerieux and Vantive.\u003c/p\u003e\n\u003cp\u003eDM declares no competing interests.\u003c/p\u003e\n\u003cp\u003eSR received support related to the present manuscript, consulting fees, honoraria for lectures and support for attending meetings and/pr travel from AOP Health. He also received honoraria for lectures from CSL Behring.\u003c/p\u003e\n\u003cp\u003eMS received support for the present manuscript, grants or contracts, consulting fees, honoraria for lectures, support for attending meetings and/or travel from AOP Health. He also participated on an Advisory Board for AOP Health and received drugs from AOP Health.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Delphi consensus process and the preparation of this manuscript were supported by an unrestricted grant from AOP ORPHAN PHARMACEUTICALS GmbH - Member of the AOP Health Group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll Authors contributed to the development of the statements discussed in the Delphi process. They participated in data analysis, contributed to the conceptualization and drafting of the manuscript. All Authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Dr. Alessandro Urbani, the independent methodologist, for his active effort in this study.\u003c/p\u003e\n\u003cp\u003eMedical writing and editorial support were provided by AKROS Bioscience S.r.l. (Pomezia, Rome, Italy). \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eV\u0026eacute;lez-Gim\u0026oacute;n M. Atrial fibrillation during septic shock. 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Int Heart J. 2020;61(2):384\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1536/ihj.19-420\u003c/span\u003e\u003cspan address=\"10.1536/ihj.19-420\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKobayashi S, Susa T, Tanaka T, Murakami W, Fukuta S, Okuda S, et al. Low-dose β blocker in combination with milrinone safely improves cardiac function and eliminates pulsus alternans in patients with acute decompensated heart failure. Circ J. 2012;76(7):1646\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1253/circj.cj-12-0033\u003c/span\u003e\u003cspan address=\"10.1253/circj.cj-12-0033\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"critical-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cric","sideBox":"Learn more about [Critical Care](http://ccforum.biomedcentral.com/)","snPcode":"13054","submissionUrl":"https://submission.nature.com/new-submission/13054/3","title":"Critical Care","twitterHandle":"@Crit_Care","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Atrial fibrillation, Septic shock, Landiolol","lastPublishedDoi":"10.21203/rs.3.rs-9269792/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9269792/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: 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.\u003c/p\u003e\n\u003cp\u003eMethods: 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.\u003c/p\u003e\n\u003cp\u003eResults: 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.\u003c/p\u003e\n\u003cp\u003eLandiolol 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.\u003c/p\u003e\n\u003cp\u003eConclusions: 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.\u003c/p\u003e","manuscriptTitle":"Use of landiolol in septic shock patients with new onset of atrial fibrillation: A European Delphi Consensus","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-09 16:01:12","doi":"10.21203/rs.3.rs-9269792/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-22T06:42:49+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-21T15:05:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180517333582463363366688704212793016954","date":"2026-04-05T08:27:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-03T07:12:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-03T03:52:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"87904934063869980521976768872606086801","date":"2026-04-03T00:46:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33432518429281591361849476902256403802","date":"2026-04-03T00:40:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-03T00:22:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-02T03:25:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-02T03:24:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"Critical Care","date":"2026-03-30T16:12:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"critical-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cric","sideBox":"Learn more about [Critical Care](http://ccforum.biomedcentral.com/)","snPcode":"13054","submissionUrl":"https://submission.nature.com/new-submission/13054/3","title":"Critical Care","twitterHandle":"@Crit_Care","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4b882e35-e4f4-4e9d-be44-097331afa3b4","owner":[],"postedDate":"April 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-22T06:54:35+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-09 16:01:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9269792","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9269792","identity":"rs-9269792","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}