Efficacy and drug-related complications of anticholinergic drugs for vagal reaction prevention during pulsed field ablation

Abstract Background Vagal responses (VR) are frequently observed during pulmonary vein isolation (PVI) with pulsed field ablation (PFA). Objective To compare the effectiveness of two different anticholinergic (AC) medications, namely Glycopyrrolate (GLY) or Atropine (ATP), for VR prophylaxis in patients undergoing PVI via a pentaspline PFA catheter. Methods Consecutive AF patients undergoing first-time PVI with PFA were prospectively enrolled at four centres between April 2023 and February 2024. Intravenous GLY 0.2mg [Group GLY] or Atropine 1mg [Group ATP] were administered prophylactically before transseptal access. Clinically relevant VRs included sinus bradycardia (<40 beats/min), asystole (>6 sec), atrioventricular block (AVB), need for temporary backup pacing. The incidence of periprocedural VRs was compared with that of patients without prophylactic AC drug administration (Group noAC). Drug-related adverse events were compared between the two anticholinergic drugs. Results We enrolled 240 (61±12 years, 60.0% males) patients (GLY:80 patients; ATP: 80 patients; noAC: 80 patients). Intraprocedural VRs were observed in 65 (27.1%) patients. GLY and ATP effectively reduced overall VRs (GLY: 7.5% vs. ATP: 11.3% vs. noAC:62.5%; p<0.001), asystole (GLY: 1.3% vs. ATP: 2.5% vs. noAC: 33.8%; p<0.001), and need for temporary backup pacing (GLY: 1.3% vs. ATP: 5.0% vs. noAC: 23.8%; p<0.001). The risk of overall drug-related adverse events (8.8% vs 0%; p=0.007) and drug-induced AF (5% vs 0%; p=0.043) was significantly higher with ATP. Conclusions Prophylactic AC drug administration effectively prevented clinically relevant VRs in patients undergoing PVI with PFA. Both AC drugs were equally highly effective, but ATP was associated with a significantly higher risk of drug-induced adverse events.