(Circulation. 1997;96:3921-3927.)
© 1997 American Heart Association, Inc.
Articles |
Adenosine-Induced Atrioventricular Block in Patients With Unexplained Syncope
The Diagnostic Value of ATP Testing
From the Section of Arrhythmology, Ospedali Riuniti, Lavagna (M.B., G.G., L.G., A.B., D.O., A.D.R.), and the Department of Cardiology and Arrhythmologic Center, Ospedale S. Maria Nuova, Reggio Emilia (C.M., N.B., G.L., G.P.), Italy.
Correspondence to Michele Brignole, MD, Via A. Grilli 164, 16041 Borzonasca (GE), Italy. E-mail brignole{at}omninet.it
Background ATP and its related nucleoside, adenosine, are ubiquitous biological compounds with potent depressant activity on the atrioventricular node. We hypothesized that an increased susceptibility of the atrioventricular node to adenosine may, in some cases, play a role in the genesis of syncope.
Methods and Results The study was performed in two parts.
In part 1, we evaluated the effects of a bolus injection of 20 mg ATP
in a group of 60 patients (57±19 years, 31 men) with syncope of
unexplained origin and in 90 control subjects without syncope (55±17
years, 46 men). In control subjects, the upper 95th percentile of the
maximum RR interval distribution, during ATP-induced
atrioventricular block (AVB), was 6000 ms. In the
syncope group, 28% of patients had a maximum RR interval above this
limit (P=.000). The distribution of the maximum RR
interval below the 95th percentile was similar in the two groups. In
part 2, we validated the ATP test in 24 patients who had the fortuitous
ECG recording of a spontaneous syncope caused by a transient
asystolic pause (AVB in 15 and sinus arrest in 9). The ATP test
caused AVB with an asystolic pause of 
6000 ms in 53% of the
patients with documented AVB but in none (0%) of the patients with
documented sinus arrest (P=.01). Among the patients with
spontaneous AVB, the ATP test was abnormal in 6 of the 7 patients
(86%) in whom all conventional investigations for syncope had been
negative and in 2 of the 8 patients (25%) who had shown positivity
(P=.03).
Conclusions An increased susceptibility to ATP testing is present in patients with SUO and patients with syncope due to paroxysmal AVB. Thus, a logical inference is that ATP testing can be used to identify patients with syncope due to paroxysmal AVB. The results of this study form the necessary background for future prospective studies with an aim to validate this assumption.
Key Words: adenosine • syncope • heart block • atrioventricular node
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