Landiolol bolus application for tachycardic dysrhythmia in the prehospital EMS setting - An observational study of a novel concept

Background: Tachydysrhythmias are a challenging aspect of emergency medicine, with atrial fibrillation being the most common. Electrical cardioversion is recommended for hemodynamically unstable patients, while treatment varies according to the dysrhythmia subtype in others. Landiolol, a relatively new ultra-short-acting cardioselective beta-blocker, may be a promising option for prehospital use due to its advantageous pharmacological properties. Methods: This observational study included all cases of Landiolol bolus administration of the Emergency Medical Service (EMS) Vienna from 08/2023 until 06/2024. Data were extracted from EMS reports and hospital records. The primary endpoint was drug safety and adverse events. Secondary outcomes were the effect on hemodynamic and rate- and rhythm control. Results: We analysed reports of 111 patients having received push-dose Landiolol (median 74 [interquartile ranges (IQR) 62–81] years; 57% female; dosage median 20 [IQR 7–20] mg). Leading symptoms were palpitations (35%), dyspnoea (26%), and chest pain (18%), with atrial fibrillation as the most common dysrhythmia (64%). No allergic reactions, relevant bradycardias or cardiac arrests were detected immediately after Landiolol administration. In 59%, an improvement in patients’ condition was reported. Rhythm control was achieved in 14%, and rate control in 44%. No effect was seen in 34%. The heart rate was significantly (median 170 [IQR 150–190] vs. median 123 [IQR 99 − 140] bpm; p < 0.001) lower after drug administration. Phenylephrine administration with a probable causal relation to Landiolol was needed in four cases (3.6%). Overall, there was no relevant effect on mean arterial blood pressure (median 90 [IQR 80–105] vs. median 91 [IQR 77–101] mmHg; p = 0.362). Conclusion: Push-dose Landiolol could be a conceivable future therapeutic option for tachydysrhythmia in the EMS setting. In particular, a high incidence of rate or rhythm control can be achieved. Utilization should be allocated to non-compensatory tachycardia only. Drug response and control groups with other drugs should be further investigated.