Esmolol is noninferior to metoprolol in achieving a target heart rate of 65 beats/min in patients referred to coronary CT angiography: A randomized controlled clinical trial.

BACKGROUND: Coronary CT angiography (CTA) is an established tool to rule out coronary artery disease. Performance of coronary CTA is highly dependent on patients' heart rates (HRs). Despite widespread use of beta-blockers for coronary CTA, few studies have compared various agents used to achieve adequate HR control. OBJECTIVE: We sought to assess if the ultrashort-acting beta-blocker intravenous esmolol is at least as efficacious as the standard of care intravenous metoprolol for HR control during coronary CTA. METHODS: Patients referred to coronary CTA with a HR >65 beats/min despite oral metoprolol premedication were enrolled in the study. We studied 412 patients (211 male; mean age, 57 +/- 12 years). Two hundred four patients received intravenous esmolol, and 208 received intravenous metoprolol with a stepwise bolus administration protocol. HR and blood pressure were recorded at arrival, before, during, immediately after, and 30 minutes after the coronary CTA scan. RESULTS: Mean HRs of the esmolol and metoprolol groups were similar at arrival (78 +/- 13 beats/min vs 77 +/- 12 beats/min; P = .65) and before scan (68 +/- 7 beats/min vs 69 +/- 7 beats/min; P = .60). However, HR during scan was lower in the esmolol group vs the metoprolol group (58 +/- 6 beats/min vs 61 +/- 7 beats/min; P < .0001), whereas HRs immediately and 30 minutes after the scan were higher in the esmolol group vs the metoprolol group (68 +/- 7 beats/min vs 66 +/- 7 beats/min; P = .01 and 65 +/- 8 beats/min vs 63 +/- 8 beats/min; P < .0001; respectively). HR </=65 beats/min was reached in 182 of 204 patients (89%) who received intravenous esmolol vs 162 of 208 of the patients (78%) who received intravenous metoprolol (P < .05). Of note, hypotension (systolic BP <100 mm Hg) was observed right after the scan in 19 patients (9.3%) in the esmolol group and in 8 patients (3.8%) in the metoprolol group (P < .05), whereas only 5 patients (2.5%) had hypotension 30 minutes after the scan in the esmolol group compared to 8 patients (3.8%) in the metoprolol group (P = .418). CONCLUSION: Intravenous esmolol with a stepwise bolus administration protocol is at least as efficacious as the standard of care intravenous metoprolol for HR control in patients who undergo coronary CTA