Characterization of Esmolol Use for Acute Aortic Syndrome at a Tertiary Academic Medical Center

Introduction: Aortic dissection or aneurysm are types of acute aortic syndrome (AAS) associated with high mortality. As a result, guidelines recommend strict heart rate and blood pressure control with anti-impulse therapy. Esmolol is a beta-1 selective beta-blocker that is a first-line agent for heart rate control in AAS at VCUHS due to its short half-life and titratability.

The purpose of this medication use evaluation was to characterize the utilization of esmolol in AAS at VCUHS and to determine what percentage of patients are achieving their heart rate goal while on esmolol therapy.


Methods: This project was a retrospective chart review of patients admitted to VCUHS with AAS from January 1, 2022 to March 31, 2025 who received esmolol for heart rate control. Patients were excluded if they received esmolol only intraoperatively.


Results: There were 113 patients were deemed eligible for inclusion in this study. The median initial heart rate goal was less than 70 beats per minute (IQR 60-80). Only 36% of patients (n=41) met their initial goal. Of those not meeting their initial goal, 67% (n=48) had their goal revised to a more lenient target. The median revised heart rate goal was less than 80 beats per minute (IQR 70-90). Only 63% of patients (n=71) met either their initial or revised goal.

Patients who did not meet their initial heart rate goal received higher maximum esmolol doses (median 200 mcg/kg/min vs. 125 mcg/kg/min) and more volume from the esmolol infusion (median 682 mL/day vs. 510 mL/day) compared to those who did meet their initial goal. The maximum dose of esmolol (300 mcg/kg/min) was reached in 24% of patients (n=27).

All but two patients were initiated on the diluted concentration of esmolol (10 mg/mL). Overall, 9% of patients (n=10) received the concentrated formulation (20 mg/mL), which requires central administration. Notably, 60% of patients receiving concentrated esmolol did not have central access.


Conclusions: Esmolol was not effective in achieving an initial heart rate goal in 64% of patients. Despite the relaxation of heart rate goals in 67% of the study population, 37% still never reached their target heart rate. Patients not meeting their initial heart rate goal required higher esmolol doses and received larger volumes from the infusion.