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

Abstract

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)]. Pilot cohort study. 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. 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. 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.