Background: Rapid sequence induction (RSI) is recommended in patients at risk of aspiration, but induced haemodynamic adverse events, including tachycardia. In elderly patients, this trial aimed to assess the impact of the addition of remifentanil during RSI on the occurrence of: tachycardia (primary outcome), hypertension (due to intubation) nor hypotension (remifentanil).Methods: In this three-arm parallel, double blind, multicentre controlled study, elderly patients (65 to 90 years old) hospitalised in three centres and requiring RSI were randomly allocated to three groups, where anaesthesia was induced with etomidate (0.3mg/kg) followed within 15seconds by either placebo, or low (0.5μg/kg), or high (1.0μg/kg) doses of remifentanil, followed by succinylcholine 1.0mg/kg. Heart rate (HR) and mean arterial pressure (MAP) were recorded before induction and after intubation.Results: In total, eighty patients were randomised and analysed. Baseline HR and MAP were similar between groups. For primary endpoint, the absolute change in HR between induction and intubation was greater in the control group (15 bpm; 95% CI [8-21]) than that in the remifentanil 0.5μg/kg group (4 bpm; 95% CI [-1-+8]; P=0.005) and the remifentanil 1.0μg/kg group (-3 bpm; 95% CI [-9-+3]; P<0.0001). The increase in MAP was greater in the placebo group than in both remifentanil groups (P<0.0001). Twice as many hypertension episodes were recorded in the placebo group compared to the remifentanil 0.5μg/kg and 1.0μg/kg groups (60%, 30%, and 28% patients respectively; P=0.032), but no placebo patients experienced hypotension episodes versus 11% and 24% in the remifentanil 0.5μg/kg and 1.0μg/kg groups respectively (P=0.016).Conclusion: Remifentanil (0.5-1.0μg/kg) prevents the occurrence of tachycardia and hypertension in elderly patients requiring RSI.