Indian Pacing Electrophysiol. J. 2003;3(1):1

Editorial

Role of Adenosine/ATP Test in Supraventricular Tachycardia

Johnson Francis, MD, DM.

Associate Professor of Cardiology, Medical College Calicut, Kerala, India.

Address for correspondence: Dr. Johnson Francis, "Pulikkottil", Thondayad, P.O. Chevarambalam, Calicut -673017, Kerala, India. Email: johnsonf@vsnl.com

           

            The successful treatment of paroxysmal supraventricular tachycardia with adenosine 5` triphosphate (ATP) was initially reported by Somlo¹ in 1955. Sharma et al² noted the value of intravenous ATP in the diagnosis and management of wide QRS complex tachycardia. ATP in incremental doses has been used for the non-invasive diagnosis of concealed accessory pathways³.

            Non-invasive diagnosis of dual AV node physiology (DAVNP) in patients with AV nodal reentrant tachycardia by administration of ATP or adenosine has been reported by different authors^4,5. Though many of the studies were using incremental dosage, single dose tests with ATP⁶ and adenosine⁷ have also been useful in the diagnosis of DAVNP. The test is useful in sinus rhythm to establish the presence of DAVNP. DAVNP is considered to be present when at least one of the following events occur following ATP injection: 1) PR interval increases or decreases by >50 ms in 2 consecutive sinus beats; 2) an AV nodal echo beat is observed; 3) AVNRT develops. In this issue of the Journal, Belhassen et al⁸ report that DAVNP is present in a relatively high proportion (36.5%) of patients following termination of AVNRT with ATP but is much less frequent (5.5%) in control patients. In addition, they show that the occurrence of DAVNP following the administration of ATP in sinus rhythm is a good predictor of its occurrence after termination of AVNRT with ATP. Thus, findings at termination of tachycardia by ATP may be useful in the noninvasive diagnosis of the mechanism of a paroxysmal supraventricular tachycardia.

            In patients with palpitations of unclear etiology, ATP test identifies those who are likely to have AVNRT or AVRT (and who are therefore likely to benefit from electrophysiological evaluation) with a high positive predictive value⁹. ATP/adenosine test is also useful in confirming the result of radiofrequency ablation of slow pathway^6,10. Among patients with no history suggestive of AVNRT, less than 3% have clinically silent DAVNP on incremental adenosine infusion¹¹. Adenosine/ATP infusion can be used a simple bedside screening test for patients with symptoms suggestive of of paroxysmal supraventricular tachycardia which is undocumented and in those in whom the mechanism of a narrow complex tachycardia is unclear. This test may be specially relevant in developing countries with limited resources, in selecting patients for further electrophysiological evaluation.

References

1. Somlo E. Adenosine triphosphate in paroxysmal tachycardia. Lancet 1955;i:1125.

2. Sharma AD, Klein GJ, Yee R. Intravenous adenosine triphosphate during wide QRS complex tachycardia: safety therapeutic efficacy and diagnostic utility. Am J Med 1990;88:337–43

3. Belhassen B, Fish R, Viskin S, et al. Adenosine-5`-triphosphate test for the non-invasive diagnosis of concealed accessory pathway. J Am Coll Cardiol 2000;36:803–10.

4. Belhassen B, Fish R, Glikson M, Glick A, Glikson M, Eldar M. Non invasive diagnosis of dual AV node physiology in patients with AV nodal reentrant tachycardia by administration of adenosine-5'-triphosphate during sinus rhythm. Circulation 1998;98:47–53.
          
5. Tebbenjohanns J, Niehaus M, Korte T, et al. Non invasive diagnosis in patients with undocumented tachycardias: value of the adenosine test to predict AV nodal reentrant tachycardia. J Cardiovasc Electrophysiol 1999;10:916–23.

6. Belhassen B, Fish R, Eldar M, Glick A, Glikson M, Viskin S. Simplified "ATP test" for noninvasive diagnosis of dual AV nodal physiology and assessment of results of slow pathway ablation in patients with AV nodal reentrant tachycardia. J Cardiovasc Electrophysiol 2000; 11:255-61

7. Toal SC, Vajifdar BU, Gupta AK, Vora AM, Lokhandwala YY. Adenosine induced PR jump on surface ECG to differentiate atrioventricular nodal re-entrant tachycardia from concealed accessory pathway mediated tachycardia: a bedside test. Heart 2002;87:37-40.

8.  Belhassen B, Fish R, Viskin S, Glick A, Glikson M, Eldar M. Incidence of dual AV node physiology following termination of AV nodal reentrant tachycardia by adenosine-5'-triphosphate: a comparison with drug administration in sinus rhythm. Indian Pacing and Electrophysiology Journal. 2003;3:3-9

9.  Viskin S, Fish R, Glick A, Glikson M, Eldar M, Belhassen B. The adenosine triphosphate test: a bedside diagnostic tool for identifying the mechanism of supraventricular tachycardia in patients with palpitations. J Am Coll Cardiol 2001;38:173-7.

10. Dierkes S, Vester EG, Dobran LJ, Perings C, Strauer BE. Adenosine in the noninvasive diagnosis of dual AV nodal conduction: use as a follow-up parameter after slow pathway ablation in AVNRT. Acta Cardiol 2001; 56:103-8.

11. Burkart TA, Scozzaro MJ, Angella FR, Jayaram KN, Gonzalez MD, Conti JB, Curtis AB. Use of adenosine as a diagnostic tool for dual atrioventricular nodal pathways: response of control patients to incremental doses of adenosine. Clin Cardiol 2002;25:263-6.