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Objective: To evaluate the efficacy and safety of a heart rate (HR) reduction protocol using intravenous esmolol as bailout for failed oral metoprolol regimens in patients undergoing coronary computed tomography angiography (CCTA) with 64-slice multidetector computed tomography (64-MDCT). Methods: Patients who underwent cardiac 64-MDCT in a single institution between 2011 and 2014 were analyzed. Those with HR above 60 beats per minute (bpm) on presentation received oral metoprolol (50-200 mg) at least one hour before CCTA. Intravenous esmolol 1-2 mg/kg was administered as a bolus whenever HR remained over 65 bpm just before imaging. The primary efficacy endpoint was HR <65 bpm during CCTA. The primary safety endpoint was symptomatic hypotension or bradycardia up to hospital discharge. Results: During the study period CCTA was performed in 947 cases. In 86% of these, oral metoprolol was the only medication required to successfully reduce HR <60 bpm. Esmolol was used in the remaining 130 patients (14%). For esmolol-treated patients mean baseline and acquisition HR were 74±14 bpm and 63±9 bpm, respectively (p<0.001). The target HR of <65 bpm was achieved in 82 of the 130 esmolol-treated patients (63%). Considering the whole population, esmolol use led to a significant increase in the primary efficacy endpoint from 86% to 95% (p<0.001). Esmolol also resulted in a statistically, but not clinically, significant reduction in systolic blood pressure (144±22 to 115±17 mmHg; p<0.001). The combined primary safety endpoint was only observed in two (1.5%) patients. Conclusion: Despite optimal use of oral beta-blockers, 14% of patients needed intravenous esmolol for HR control. The pre-medication combination of oral metoprolol and on-demand administration of intravenous esmolol was safe and effective and enabled 95% of patients to be imaged with HR below 65 bpm. Document downloaded from http://www.elsevier.es, day 21/09/2017. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. Document downloaded from http://www.elsevier.es, day 21/09/2017. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. Conclusão: Apesar da utilização sistemática de betabloqueante oral, 14% dos casos necessitaram de esmolol endovenoso para controlo adequado de FC. Pré-medicação combinada de metoprolol oral e esmolol endovenoso quando necessária foi segura e eficaz, e permitiu que 95% dos doentes apresentassem FC <65 bpm no momento da aquisição de imagem. S. Aguiar Rosa et al. PALAVRAS-CHAVE

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