Adenosine in the treatment of supraventricular tachycardia: 5 years of experience (2002-2006)

Safety of adenosine for pediatric tachyarrhythmia treatment in the emergency department: a multi-hospital 10-year cross-sectional study

BACKGROUND

Supraventricular tachycardia is the most common dysrhythmia in children. Initial vagal maneuvers are successful less than half of the time. Adenosine, a potent AV nodal blocker with a short half-life, is recommended as first line pharmacotherapy. Minor side effects from adenosine are common, but report of serious side effects such as sustained ventricular tachycardia, torsades de pointes, syncope or hypotension are confined to small case series or studies greater than 20 years old. We aimed to specifically identify the incidence of serious side effects of adenosine in children in the emergency department.

METHODS

Between 2002 and 2022, all children less than 18 years old who received adenosine for tachyarrhythmia treatment in two emergency departments were included. The electronic record was reviewed for demographic information, patient history, treatments given, and side effects or complications were observed. Electrocardiograms before, during and after adenosine administration were reviewed.

RESULTS

77 patients met inclusion criteria. There were 74 patients with an initial rhythm of typical SVT. The other three patients included one with a junctional rhythm, one with atrial fibrillation, and one with an undetermined narrow complex tachycardia. 49 patients had cardiac rhythm monitoring during adenosine administration. 17 of these patients had three or more consecutive ventricular beats following adenosine, however no patients required treatment. No patients had syncope. One patient had brief hypotension after adenosine that normalized without intervention. Four patients were electrically cardioverted after adenosine, all for persistent dysrhythmias: two for persistent SVT with hypotension, one for atrial fibrillation and one for an undetermined rhythm. Twelve patients were placed on continuous antiarrhythmic medication for persistent SVT. Age, gender, prior SVT history, initial adenosine dose, and need for additional doses were not significant risk factors for a prolonged sinus pause or greater than two ventricular beats.

CONCLUSIONS

Adenosine treatment in typical supraventricular tachycardia in pediatric patients is safe.

Adenosine response and failure to convert paroxysmal supraventricular tachycardia in the emergency department

BACKGROUND AND IMPORTANCE

Although adenosine is the recommended first-line therapy for patients with paroxysmal supraventricular tachycardia (SVT), it may fail to restore normal sinus rhythm. The factors associated with this failure remain unclear.

OBJECTIVE

To assess the response rate to adenosine and identify the factors causing adenosine failure in the management of paroxysmal SVT.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective study was conducted on adult patients diagnosed with paroxysmal SVT and treated with adenosine in the emergency departments of two large tertiary hospitals between June 2015 and June 2021.

OUTCOME MEASURE AND ANALYSIS

The primary outcome of the study was the patient response to adenosine, defined as the restoration of sinus rhythm documented in the patients' files. Backward-stepwise multivariate logistic regression was used to examine the predictors of adenosine failure based on the overall response to adenosine therapy.

MAIN RESULTS

A total of 404 patients, with a mean age of 49 (SD 15) years and a BMI of 32 (SD 8) kg/m 2 , and treated with adenosine for paroxysmal SVT, were included. Sixty-nine percent of patients were women. The overall response rate to any adenosine dose was 86% (n = 347). The baseline heart rate did not significantly differ between adenosine responders and non-responders (179.6 ± 23.1 vs. 183.2 ± 23.4). An association was observed between the history of paroxysmal SVT and successful response to adenosine (odds ratio = 2.08; 95% confidence interval 1.05-4.11).

CONCLUSION

The findings of this retrospective study suggested that the use of adenosine restored normal sinus rhythm in 86% of patients with paroxysmal SVT. Furthermore, a history of paroxysmal SVT and older age were associated with an increased chance of adenosine success.

Comparison of sinus conversion rates and body weights after 6 mg adenosine administration in supraventricular tachycardia

BACKGROUND

To evaluate the relationship between body weight and the success rate of supraventricular tachycardia (SVT) termination after an initial 6-mg adenosine administration.

METHODS

This retrospective observational study was conducted with medical records of patients who visited a single tertiary emergency department and underwent an electrophysiologic study with an SVT diagnosis. Patients under 18 years of age or those with SVT aberrancy, recurring SVT after radiofrequency catheter ablation, premedication of non-dihydropyridine calcium channel blocker, and signs of shock were excluded.

RESULTS

Data from 124 patients were collected. There were 69 women (55.6%); mean age, 49.7 years. The mean weight and height were 66.8 kg and 164.8 cm, respectively. Adenosine dose was 0.09 mg/kg. For the first sinus conversion (SC) success group (83 patients, 67%), the mean weight, height, and adenosine dose were 61.0 ± 11.5 kg, 161.9 ± 8.1 cm, and 0.10 ± 0.02 mg/kg. For the first SC failure group, these values were 78.4 ± 17.0 kg, 170.7 ± 8.9 cm, and 0.079 ± 0.02 mg/kg, respectively. To evaluate factors associated with the first SC, we performed bivariate logistic regression with weight (odds ratio [OR]: 1.093; 95% confidence interval [CI]: 1.045-1.144; P < 0.001) and height (OR: 1.071; 95% CI: 1.008-1.138; P = 0.027). Receiver operating characteristics curves and the cut-off values for adenosine dose and weight were 0.90 mg/kg and 66.5 kg with 71.1% sensitivity and 73.2% specificity (area under the curve: 0.814; 95% CI: 0.73-0.90; P < 0.001).

CONCLUSION

Weight and height were significant predictors of the first SC success rate among SVT patients. Consequentially, it is necessary to consider other adenosine administration methods, including increasing the initial drug dose or changing the flushing strategy after adenosine injection.

Management of gestational supraventricular tachycardia with a 'modified' modified Valsalva manoeuvre

A 36 year old woman with chest pain and palpitations at 34 weeks gestation (gravidity 2, parity 1) presented to the emergency department where she was found to be in supraventricular tachycardia (SVT). This patient had an earlier episode of SVT during the same pregnancy that was managed with intravenous adenosine. During both presentations a REVERT trial style 'modified' Valsalva manoeuvre (including supine positioning with passive leg raise) was attempted without success. Acknowledging the potential for vena caval compression in pregnant patients while in the Trendelenburg position, the same manoeuvre was attempted with the novel additional of 45 degree left pelvic tilt. This 'modified' modified Valsalva was successful in restoring sinus rhythm, suggesting this technique may warrant further investigation as a viable treatment for pregnant patients with hemodynamically stable SVT.

High-Dose Adenosine for Treatment of Refractory Supraventricular Tachycardia in an Emergency Department of an Academic Medical Center: A Case Report and Literature Review

BACKGROUND

Symptomatic tachycardia is a common admission diagnosis in the emergency department (ED). This can be a life-threatening condition and requires immediate attention. Supraventricular tachycardia (SVT) is commonly treated with adenosine, and successful treatment is limited to atrioventricular (AV) node-dependent SVTs as adenosine causes a transient heart block. However, there are limited data available for instances when the recommended dosing regimen (6 mg, 12 mg, 12 mg) fails to terminate SVT.

CASE REPORT

A 33-year old man was evaluated in the ED with an electrocardiogram revealing a regular narrow complex tachycardia with a heart rate of 180 beats/min and a rhythm consistent with SVT. He reported experiencing 3 days of fatigue, myalgias, palpitations, and dyspnea on exertion, but was otherwise hemodynamically stable. Attempts at chemical cardioversion with standard doses of adenosine (6 mg, 12 mg, and 12 mg) were given without success. After consultation with the cardiology service, additional doses of 24 mg and then 36 mg of adenosine were administered. The last dose of 36 mg produced sustained conversion and return to a normal sinus rhythm. The patient later underwent radiofrequency ablation of a left-sided orthodromic reciprocating accessory pathway. After 3 months of medical management, the patient had an implantable cardiac defibrillator placed for prevention of sudden cardiac death. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Each case of SVT demands immediate attention from an emergency physician. It is imperative that providers be aware of the limitations of adenosine and when it may be appropriate to deviate from standard dosing recommendations. This is in addition to collaborating with an expert in cardiac electrophysiology when initial management tactics are not successful.

Cardiac purinergic signalling in health and disease

This review is a historical account about purinergic signalling in the heart, for readers to see how ideas and understanding have changed as new experimental results were published. Initially, the focus is on the nervous control of the heart by ATP as a cotransmitter in sympathetic, parasympathetic, and sensory nerves, as well as in intracardiac neurons. Control of the heart by centers in the brain and vagal cardiovascular reflexes involving purines are also discussed. The actions of adenine nucleotides and nucleosides on cardiomyocytes, atrioventricular and sinoatrial nodes, cardiac fibroblasts, and coronary blood vessels are described. Cardiac release and degradation of ATP are also described. Finally, the involvement of purinergic signalling and its therapeutic potential in cardiac pathophysiology is reviewed, including acute and chronic heart failure, ischemia, infarction, arrhythmias, cardiomyopathy, syncope, hypertrophy, coronary artery disease, angina, diabetic cardiomyopathy, as well as heart transplantation and coronary bypass grafts.

Dexmedetomidine: therapeutic use for the termination of reentrant supraventricular tachycardia

OBJECTIVES

The current drug of choice for reentrant supraventricular tachycardia (SVT) is adenosine followed by verapamil or diltiazem. Although limitations and significant adverse events have been encountered over the years, an alternative effective and safe agent has not been available. Dexmedetomidine has recently been shown to have potential antiarrhythmic effects, and here we describe our experience in the acute termination of reentrant SVT.

DESIGN

Retrospective case series.

SETTING

Quaternary University Children's Hospital, Cardiac Intensive Care Unit.

PATIENTS

Patients who received dexmedetomidine for SVT in the past 5 years.

INTERVENTIONS

None.

OUTCOME MEASURES

SVT episodes terminated with dexmedetomidine were compared with episodes terminated with adenosine.

RESULTS

Fifteen patients, median age of 10 days (6-16), were given 27 doses of dexmedetomidine, mean dose 0.7 ± 0.3 mcg/kg, for a total of 27 episodes of SVT. Successful termination occurred in 26 episodes (96%) at a median time of 30 seconds (20-35). Duration of sinus pause was 0.6 ± 0.2 seconds, there was one episode of hypotension and no bradycardia and sedation lasted for 34 ± 8 minutes. Five patients received 27 doses of adenosine, with an overall successful cardioversion in 17 patients (63%) (P= .0017). Transient bradycardia and hypotension was seen in three patients (11%), agitation in 16 patients (59%), and broncospasm in one patient. Median sinus pause was 2.5 seconds (2-9) (P < .001).

CONCLUSIONS

Dexmedetomidine appears to have novel antiarrhythmic properties for the acute termination of reentrant SVT. Although adenosine is very effective, dexmedetomidine may prove to possess a more favorable therapeutic profile with increased effectiveness and fewer side effects.

Carotid body function in aged rats: responses to hypoxia, ischemia, dopamine, and adenosine

The carotid body (CB) is the main arterial chemoreceptor with a low threshold to hypoxia. CB activity is augmented by A(2)-adenosine receptors stimulation and attenuated by D(2)-dopamine receptors. The effect of aging on ventilatory responses mediated by the CB to hypoxia, ischemia, and to adenosine and dopamine administration is almost unknown. This study aims to investigate the ventilatory response to ischemia and to adenosine, dopamine, and their antagonists in old rats, as well as the effect of hypoxia on adenosine 3',5'-cyclic monophosphate (cAMP) accumulation in the aged CB. In vivo experiments were performed on young and aged rats anesthetized with pentobarbitone and breathing spontaneously. CB ischemia was induced by bilateral common carotid occlusions. cAMP content was measured in CB incubated with different oxygen concentrations. Hyperoxia caused a decrease in cAMP in the CB at all ages, but no differences were found between normoxia and hypoxia or between young and old animals. The endogenous dopaminergic inhibitory tonus is slightly reduced. However, both the ventilation decrease caused by exogenous dopamine and the increase mediated by A(2A)-adenosine receptors are not impaired in aged animals. The bradycardia induced by adenosine is attenuated in old rats. The CB's peripheral control of ventilation is preserved during aging. Concerns have also arisen regarding the clinical usage of adenosine to revert supraventricular tachycardia and the use of dopamine in critical care situations involving elderly people.

Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia. Drugs or, when appropriate, pacing may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation.

Part 10: Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

Note From the Writing Group: Throughout this article, the reader will notice combinations of superscripted letters and numbers (eg, “Family Presence During ResuscitationPeds-003”). These callouts are hyperlinked to evidence-based worksheets, which were used in the development of this article. An appendix of worksheets, applicable to this article, is located at the end of the text. The worksheets are available in PDF format and are open access.