Reproducibility of the adenosine-5'-triphosphate test in vasovagal syndrome

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.

The use of adenosine and adenosine triphosphate testing in the diagnosis, risk stratification and management of patients with syncope: current evidence and future perspectives

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.

Treatment of unexplained syncope: a multicenter, randomized trial of cardiac pacing guided by adenosine 5'-triphosphate testing

BACKGROUND

The origin of 40% of syncope cases remains unknown even after a complete diagnostic workup. Previous studies have suggested that ATP testing has value in selecting successful therapy. This patient-blinded, multicenter, randomized superiority trial tested whether, in patients with syncope of unknown origin, selecting cardiac pacing in those with a positive ATP test leads to fewer recurrences than those who do not receive pacing.

METHODS AND RESULTS

From 2000 to 2005, 80 consenting patients (mean age, 75.9±7.7 years; 81% women; 56% without diagnosed structural heart disease) with syncope of unknown origin and atrioventricular or sinoatrial block lasting >10 seconds (average, 17.9±6.8 seconds) under ATP administration (20-mg IV bolus) were recruited from 10 hospitals, implanted with programmable pacemakers, and randomized to either active pacing (dual-chamber pacing at 70 bpm) or backup pacing (atrial pacing at 30 bpm). Patients were followed up regularly for up to 5 years for any syncope recurrence, the primary outcome. Mean follow-up was 16 months. Syncope recurred in 8 of 39 patients (21%) randomized to active pacing and in 27 of 41 (66%) randomized to backup pacing (control), yielding a hazard ratio of 0.25 (95% confidence interval, 0.12-0.56). After recurrence, the 27 recurrent control patients were reprogrammed to active pacing, and only 1 reported subsequent syncope.

CONCLUSION

This study suggests that, in elderly patients with syncope of unknown origin and positive ATP tests, active dual-chamber pacing reduces syncope recurrence risk by 75% (95% confidence interval, 44-88).

CLINICAL TRIAL REGISTRATION

URL: http://www.controlled-trials.com/ISRCTN00029383. Unique identifier: ISRCTN00029383.

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

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.

Adenosine test in the diagnosis of unexplained syncope: marker of conducting tissue disease or neurally mediated syncope?

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.

Epidemiology, clinical features, and follow-up of patients with syncope and a positive adenosine triphosphate test result

OBJECTIVES

We sought to evaluate epidemiology, clinical features, and outcomes of patients with syncope and an abnormal response to adenosine triphosphate (ATP).

BACKGROUND

Syncope remains of unknown origin in almost 30% of the patients. Injection of ATP induces in some of these patients, but not in control patients, a ventricular pause > or =6 s.

METHODS

Patients with syncope of unknown origin had an intravenous injection of 20 mg of ATP. All patients had a tilt test.

RESULTS

Among 214 patients, 19 (8.9%) had a positive ATP test result. The proportion of positive test results was higher (p < 0.002) in women (14.3%) than in men (2.2%). Ten patients (4.7%) had positive ATP and tilt test results. These patients (exclusively women) were older (p < 0.05) at the time of their fist syncope than the 67 patients with a negative ATP test result but a positive tilt test result. There was a trend for these two test results to be correlated (p = 0.07). Side effects were of short duration and benign. The mean duration of pauses was longer in women (p = 0.009). During a mean period of 31 +/- 14 months, recurrences of syncope were reported in 25% of patients.

CONCLUSIONS

The ATP test is a safe test with an "abnormal" result in <10% of patients with syncope of unknown origin. The profile of these patients is characteristic.

[The adenosine-5'-triphosphate (ATP) test: a diagnostic tool in the management of syncope of unknown origin. Basic and clinical aspects]

The prevalence of syncope increases in elderly population. An inappropriate reflex reaction of the autonomous nervous system in specific circumstances is responsible for symptoms in more than 50% of cases. These neurocardiogenic or vasovagal syncopes are due to a vasoplegia or to a cardio-inhibitory reflex or to the association of both mechanisms. Reproducing the symptoms may contribute to identify the responsible mechanism of syncope; this objective is partly reached by the head-up tilt test--a provocative test--which reproduces symptoms in about half of the cases, mainly by provoking a severe vasodilation with fall of blood pressure. On the opposite, the ATP test (20 mg i.v. bolus)--a descriptive test--provokes a strong cardio-inhibitory reflex independent from external factors like body position but it must be undertaken in a calm environment for preventing any anticipative sympathetic reaction. The test is considered positive if ATP produces a cardiac pause longer than 10 seconds and related symptoms are not taken into account for assessing the final result. ATP test positivity increases with age and with the presence of cardiac diseases. Permanent dual chamber pacing at 70 bpm has been shown to reduce significantly the syncope recurrences in patients with positive ATP test and to have no influence on patients with a negative test. The use of ATP test should be extended to all syncope screening. Its positivity identifies a group of patients in whom the mechanism of the syncope is susceptible to be improved by a permanent dual chamber pacing.