Atrioventricular Nodal Blocking Agents and Adverse Outcomes Following Cardioversion at a Rural Hospital

Direct current cardioversion (DCCV) is a well-established procedure for terminating various tachyarrhythmias. Recommendations for pre-operative adjustment of atrioventricular nodal blocking agents (AVNBA) to minimize bradyarrhythmia are lacking.

We performed a retrospective analysis assessing safety and outcomes for our practice of holding AVNBA prior to DCCV. Adult patients with an elective DCCV from 10/01/2015 to 9/08/2023 were included and grouped into AVNBA held versus not held. Primary outcomes were perioperative bradyarrhythmia and 30 day bradyarrhythmia. Secondary outcomes included hypotension, 30 day tachyarrhythmia, ER visits, and other adverse events. Multilevel logistic regression models adjusted for demographics, comorbidities, and post-discharge treatments were run.

The study included 247 procedures (68% male, average age 70.6 years), with 150 (61%) in the AVNBA not held group and 97 (39%) in the AVNBA held group. At 30 day follow up, the AVNBA not held group had higher rates of recurrent tachyarrhythmia (39% vs. 25%, p = 0.019). After risk adjustment, antiarrhythmic drug use predicted perioperative (aOR = 4.46; 95% CI = 1.68-11.89) and 30 day bradyarrhythmia (aOR = 2.81; 95% CI = 1.30-6.09). AVNBA holding was not predictive of either outcome. After risk adjustment, AVNBA holding was not a significant predictor of 30 day tachyarrhythmia recurrence; baseline antiarrhythmic drug use was associated with lower odds of recurrence (aOR = 0.38; 95% CI = 0.19-0.76).

Holding AVNBA was not predictive of peri-op or 30 day bradyarrhythmia after risk adjustment. Not holding AVNBA was associated with higher rates of recurrent tachyarrhythmia, but there was no association after risk adjustment. Our study reaffirms that elective DCCV is a safe and effective procedure, regardless of AVNBA holding status.