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Matthews GDK, Grace AA. Unmasking Adenosine: The Purinergic Signalling Molecule Critical to Arrhythmia Pathophysiology and Management. Arrhythm Electrophysiol Rev 2020; 8:240-248. [PMID: 32685154 PMCID: PMC7358948 DOI: 10.15420/aer.2019.05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Adenosine was identified in 1929 and immediately recognised as having a potential role in therapy for arrhythmia because of its negative chronotropic and dromotropic effects. Adenosine entered mainstream use in the 1980s as a highly effective agent for the termination of supraventricular tachycardia (SVT) involving the atrioventricular node, as well as for its ability to unmask the underlying rhythm in other SVTs. Adenosine has subsequently been found to have applications in interventional electrophysiology. While considered a safe agent because of its short half-life, adenosine may provoke arrhythmias in the form of AF, bradyarrhythmia and ventricular tachyarrhythmia. Adenosine is also associated with bronchospasm, although this may reflect irritant-induced dyspnoea rather than true obstruction. Adenosine is linked to numerous pathologies relevant to arrhythmia predisposition, including heart failure, obesity, ischaemia and the ageing process itself. This article examines 90 years of experience with adenosine in the light of new European Society of Cardiology guidelines for the management of SVT.
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Affiliation(s)
- Gareth DK Matthews
- Cambridge University NHS Foundation Trust, Cambridge, UK; Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Andrew A Grace
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK; Department of Biochemistry, University of Cambridge, Cambridge, UK
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Tajdini M, Aminorroaya A, Rahimi B, Mortazavi SH, Vasheghani Farahani A, Sadeghian S, Easapour Moghadam M, Soltani D, Bozorgi A. Comparison of trinitroglycerin and adenosine as provocative agents for head-up tilt test in patients with unexplained syncope: a semi-crossover randomized clinical trial with prospective follow-up. J Interv Card Electrophysiol 2020; 60:31-39. [PMID: 31907833 DOI: 10.1007/s10840-019-00652-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 10/22/2019] [Indexed: 12/01/2022]
Abstract
PURPOSE Head-up tilt test (HUTT) is a reasonable diagnostic evaluation for patients with suspected vasovagal syncope; however, its lengthy duration is a remarkable limitation. Although adenosine (AD), as an alternative provocative agent, is a promising option for tackling this shortcoming, it received little appreciation in the literature. We aimed to compare the efficacy and the time to elicit a positive response to HUTT for sublingual trinitroglycerin (TNG) and intravenous AD. Furthermore, we evaluated patients' outcomes in the follow-up. METHODS Patients with a chief complaint of transient loss of consciousness (TLOC) were evaluated. We randomized patients with the diagnosis of unexplained syncope after diagnostic evaluations, to undergo TNG-augmented HUTT or AD-augmented HUTT. They were crossed over to receive the other medication in case of negative response to the test. In the follow-up, we evaluated traumatic and non-traumatic TLOCs, hospitalization due to syncope, and death in patients. RESULTS We randomized 132 patients (41.70 ± 19.37 years, 52.3% female) to receive TNG (n = 66) or AD (n = 66). Respectively, the positivity rate of TNG and AD for the first and the crossover-HUTT was 31.1% and 26.7%, and 20.5% and 26.2% with no statistically significant differences in both tests (P ˃ 0.50). The time to positive response was significantly shorter for AD than TNG (P < 0.001). In the follow-up, re-admission was significantly more prevalent in HUTT-negative patients compared to HUTT-positive patients (P = 0.04). CONCLUSIONS We found that diagnostic yield of TNG and AD in HUTT is comparable, while AD acts 4 times faster than TNG in evoking a vasovagal response.
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Affiliation(s)
- Masih Tajdini
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Arya Aminorroaya
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Universal Scientific Education and Research Network, Tehran, Iran
| | - Behzad Rahimi
- Department of Cardiology, Urmia University of Medical Sciences, Urmia, Iran
| | | | | | - Saeed Sadeghian
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Danesh Soltani
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Bozorgi
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
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Autonomic uprising: the tilt table test in autonomic medicine. Clin Auton Res 2019; 29:215-230. [DOI: 10.1007/s10286-019-00598-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/21/2019] [Indexed: 12/18/2022]
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Abstract
Syncope represents one of the most frequent reasons for consultation in the emergency department. A proper identification will allow a precise etiologic approach and the optimization of delivery of health resources.
Once knowing the classification of syncope; it is the clinical interrogatory what enables to discriminate which of these patients present with a neurogenic mediated syncope or a cardiac mediated syncope. The use of diagnostic methods such as the tilt test, will clarify what type of neurally mediated syncope predominates in the patient.
The electrocardiogram is the cornerstone in the identification of those patients who had a true episode of self-limited or aborted sudden death as the first manifestation of their syncope, a fact which provides prognostic and therapeutic information that will impact the morbidity and mortality.
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Affiliation(s)
- William Uribe
- Departamento de Electrofisiología, Arritmias y Marcapasos, Centros Especializados en Salud Cardiología San Vicente, Fundación Medellín y Rionegro, Colombia; Universidades CES, Medellín, Colombia; Universidad Pontificia Bolivariana, Medellín, Colombia. Address: Carrera 43 36-02, Torre Norte, Piso 11, Medellín, Colombia.
| | - Adrián Baranchuk
- Division of Cardiology, Kingston General Hospital, Queens University, Kingston, Ontario, Canada
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Fragakis N, Antoniadis AP, Saviano M, Vassilikos V, Pappone C. The use of adenosine and adenosine triphosphate testing in the diagnosis, risk stratification and management of patients with syncope: current evidence and future perspectives. Int J Cardiol 2015; 183:267-73. [PMID: 25725201 DOI: 10.1016/j.ijcard.2015.01.089] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 12/08/2014] [Accepted: 01/03/2015] [Indexed: 10/24/2022]
Abstract
Syncope is a significant source of cardiovascular-related morbidity yet the etiology is frequently obscure and the identification of patients at highest risk is challenging. Adenosine (AD) and adenosine triphosphate (ATP) administrations have been suggested as potentially useful non-invasive tools in the diagnostic workup of patients with neurally-mediated or bradycardia-related syncope. It has been postulated that both compounds by modulating the autonomic innervation in the heart and exerting negative chronotropic and dromotropic effects in the conduction system, may unmask the mechanism of syncope. However, the clinical implications derived from the efficacy of both tests in the investigation of syncope remain unclear mainly due to inconclusive and occasionally contradictory results of published studies. This review article summarizes recent and past information in the use of ATP and AD in the investigation of syncope with emphasis on clinical trials. We present the current level of evidence for the use of these agents in clinical practice, identify areas where further research is warranted and highlight the future perspectives of these agents as complements to an accurate risk-stratification of patients with syncope.
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Affiliation(s)
- Nikolaos Fragakis
- 3rd Cardiology Department, Hippokration Hospital, Aristotle University Medical School, Thessaloniki, Greece.
| | - Antonios P Antoniadis
- 3rd Cardiology Department, Hippokration Hospital, Aristotle University Medical School, Thessaloniki, Greece
| | - Massimo Saviano
- Department of Arrhythmology, Maria Cecilia Hospital, Cotignola, Italy
| | - Vassilios Vassilikos
- 3rd Cardiology Department, Hippokration Hospital, Aristotle University Medical School, Thessaloniki, Greece
| | - Carlo Pappone
- Department of Arrhythmology, Maria Cecilia Hospital, Cotignola, Italy
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Watanabe N, Kawasaki S, Oonishi Y, Onuma Y, Munetsugu Y, Itou T, Onuki T, Miyoshi F, Minoura Y, Adachi T, Kawamura M, Asano T, Tanno K, Kobayashi Y. Characteristics of head-up tilt testing with additional adenosine compared with head-up tilt testing with isoproterenol and isosorbide dinitrate. J Arrhythm 2014. [DOI: 10.1016/j.joa.2014.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Mittal S, Lerman BB. Reply to the Editor:. J Cardiovasc Electrophysiol 2009. [DOI: 10.1046/j.1540-8167.2004.04013.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Parry SW, Chadwick T, Gray JC, Bexton RS, Tynan M, Bourke JP, Nath S. The intravenous adenosine test: a new test for the identification of bradycardia pacing indications? A pilot study in subjects with bradycardia pacing indications, vasovagal syncope and controls. QJM 2009; 102:461-8. [PMID: 19468041 DOI: 10.1093/qjmed/hcp048] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Intravenous adenosine has recently been used in the diagnosis of unexplained syncope, but there is no consensus as to the meaning of a 'positive' test. The objective is to determine the sensitivity and specificity of intravenous adenosine testing in the diagnosis of bradycardia-pacing indications [sinus node dysfunction(SND), atrio-ventricular block (AVB) and cardio-inhibitory carotid sinus syndrome (CSS)]. DESIGN Pilot cohort study. METHODS Patients-(i) Bradycardia-pacing group: Consecutive patients referred for pacing for SND, AVB and CSS; (ii) Consecutive head-up tilt (HUT)-positive VVS patients. Controls-(i) Simple controls (S-Con: normal examination/ECG) and (ii) Electrophysiology controls (EP-Con: consecutive subjects referred for accessory pathway ablation). Pacing referrals and EP-Con had electrophysiology studies to confirm referral diagnosis and exclude others. All subjects had bolus injection of 20 mg intravenous adenosine during continuous ECG and blood pressure monitoring (positive test: >or=6 s asystole, >or=10 s high-degree AVB post-injection). Sensitivity, specificity, safety and tolerability of the test were measured. RESULTS Of 264 potential participants (4 SND, 8 AVB, 7 CSS, 10 VVS, 10 EP-Con and 11 S-Con) 50 were studied. All (100%) of the bradycardia-pacing group were adenosine test-positive, as were 6 (60%) VVS. None (0%) and 3 (27%) of the EP- and S-Con groups were positive. Adenosine testing was 100% sensitive and 86% specific for bradycardia-pacing indications, and 100% specific using the diagnostically 'clean' EP-Con results. There were no significant adverse or side effects. CONCLUSION Adenosine testing reliably identified patients with definitive bradycardia-pacing indications in whom alternative diagnoses were excluded. Further work is needed to evaluate the role of this test in the diagnosis of unexplained syncope.
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Affiliation(s)
- S W Parry
- Falls and Syncope Service, Institute for Ageing and Health, Newcastle University, Royal Victoria Infirmary, Newcastle upon Tyne, UK.
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Mustafa SJ, Morrison RR, Teng B, Pelleg A. Adenosine receptors and the heart: role in regulation of coronary blood flow and cardiac electrophysiology. Handb Exp Pharmacol 2009:161-88. [PMID: 19639282 PMCID: PMC2913612 DOI: 10.1007/978-3-540-89615-9_6] [Citation(s) in RCA: 180] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2023]
Abstract
Adenosine is an autacoid that plays a critical role in regulating cardiac function, including heart rate, contractility, and coronary flow. In this chapter, current knowledge of the functions and mechanisms of action of coronary flow regulation and electrophysiology will be discussed. Currently, there are four known adenosine receptor (AR) subtypes, namely A(1), A(2A), A(2B), and A(3). All four subtypes are known to regulate coronary flow. In general, A(2A)AR is the predominant receptor subtype responsible for coronary blood flow regulation, which dilates coronary arteries in both an endothelial-dependent and -independent manner. The roles of other ARs and their mechanisms of action will also be discussed. The increasing popularity of gene-modified models with targeted deletion or overexpression of a single AR subtype has helped to elucidate the roles of each receptor subtype. Combining pharmacologic tools with targeted gene deletion of individual AR subtypes has proven invaluable for discriminating the vascular effects unique to the activation of each AR subtype. Adenosine exerts its cardiac electrophysiologic effects mainly through the activation of A(1)AR. This receptor mediates direct as well as indirect effects of adenosine (i.e., anti-beta-adrenergic effects). In supraventricular tissues (atrial myocytes, sinuatrial node and atriovetricular node), adenosine exerts both direct and indirect effects, while it exerts only indirect effects in the ventricle. Adenosine exerts a negative chronotropic effect by suppressing the automaticity of cardiac pacemakers, and a negative dromotropic effect through inhibition of AV-nodal conduction. These effects of adenosine constitute the rationale for its use as a diagnostic and therapeutic agent. In recent years, efforts have been made to develop A(1)R-selective agonists as drug candidates that do not induce vasodilation, which is considered an undesirable effect in the clinical setting.
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Affiliation(s)
- S Jamal Mustafa
- Department of Physiology and Pharmacology, School of Medicine, West Virginia University, Morgantown, WV 26505-9229, USA.
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Parry SW, Nath S, Bourke JP, Bexton RS, Kenny RA. Adenosine test in the diagnosis of unexplained syncope: marker of conducting tissue disease or neurally mediated syncope? Eur Heart J 2006; 27:1396-400. [PMID: 16574690 DOI: 10.1093/eurheartj/ehi844] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Adenosine test (supine administration of a 20 mg intravenous bolus with electrocardiographic and blood pressure monitoring) has been endorsed by the European Society of Cardiology guidelines on syncope management as an 'experimental' test in the diagnosis of unexplained syncope. The test is quick and cheap, but there is no consensus as to what condition, if any, the adenosine test is exposing, with conducting tissue disease and neurally mediated syncope proposed by various authors. In this article, we review the possible mechanisms underlying a positive adenosine test, its safety, and a comprehensive examination of the literature supporting each of the putative causal diagnoses.
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Affiliation(s)
- Steve W Parry
- Falls and Syncope Service, Royal Victoria Infirmary, Newcastle upon Tyne, UK.
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Fisher JD. EDITORIAL COMMENT:. Tilt Testing Made Easy? Pacing Clin Electrophysiol 2005; 28:33. [PMID: 15660800 DOI: 10.1111/j.1540-8159.2005.09546.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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