Use of intravenous adenosine in sinus rhythm as a diagnostic test for latent preexcitation

doi:10.1016/0002-9149(90)91428-9

The American Journal of Cardiology

Volume 65, Issue 13, 1 April 1990, Pages 868-873

https://doi.org/10.1016/0002-9149(90)91428-9 Get rights and content

Abstract

In a proportion of patients with left free wall accessory connections, preexcitation is apparent only during atrial arrhythmias or atrial pacing (latent preexcitation). These patients may be at risk of a rapid ventricular response to atrial fibrillation despite the absence of preexcitation in sinus rhythm. The ability of intravenous adenosine to unmask latent preexcitation was evaluated in 22 patients with a history of documented supraventricular tachycardia and a normal electrocardiogram during sinus rhythm. Preexcitation was unmasked in response to adenosine in 4 patients: all 4 were shown to have latent preexcitation at electrophysiologic study. In 12 patients atrioventricular (AV) nodal conduction delay or block was induced without preexcitation after adenosine (first-degree AV block in 8, second-degree block in 4): at subsequent electrophysiologic study none of these patients was found to have latent preexcitation. Five patients had little or no PR prolongation in response to adenosine: of these, 2 were shown to have latent preexcitation at electrophysiologic study. Atrial fibrillation was induced in 1 patient and a narrow complex regular tachycardia in another after intravenous adenosine. Intravenous adenosine during sinus rhythm is capable of producing AV nodal conduction delay or block in 73% of patients with a history of supraventricular tachycardia: in these patients adenosine provides a diagnostic test that is both 100% sensitive and 100% specific for latent preexcitation. In those patients in whom adenosine does not produce AV conduction delay or block, further investigation is required to establish or refute the diagnosis of latent preexcitation.

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Preexcitation syndrome can be the cause of reentrant tachycardia; in this case it is called Wolff–Parkinson–White syndrome. The preferred treatment is often ablation of accessory pathway. The main problem is related to the risk of sudden death that might complicate the follow-up and be the first event in patients with asymptomatic preexcitation. The risk of sudden death remains rare and should be compared with the risks and success of ablation of accessory pathway. Generally, noninvasive studies are unable to correctly predict the risk. Electrophysiological study is the best means to detect the risk of sudden death, evaluate the nature of the symptoms, and discuss ablation.
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In our experience patients are generally stressed at the beginning of transesophageal study, so they have more vagotonic reactions during intracardiac study. Adenosine by blocking the conduction in the AV node was used to unmask a preexcitation syndrome [19,20], but was not used in the present study. Electrophysiological study and atrial pacing remain the most reliable technique to identify anterograde conduction through an accessory pathway [21].
Electrocardiographic criteria of preexcitation syndrome are sometimes not visible on ECG in sinus rhythm (SR). The purpose of the study was to evaluate the significance of unapparent preexcitation syndrome in SR, when overt conduction through accessory pathway (AP) was noted at atrial pacing.
Anterograde conduction through atrioventricular AP was identified at electrophysiological study (EPS) in 712 patients, studied for tachycardia (n = 316), syncope (n = 89) or life-threatening arrhythmia (n = 55) or asymptomatic preexcitation syndrome (n = 252). ECG in SR at the time of EPS was analysed.
78 patients (11%) (group I) had a normal ECG in SR and anterograde conduction over AP at atrial pacing; 634 (group II) had overt preexcitation in SR. Group I was as frequently asymptomatic (35%) as group II (35%), had as frequently tachycardias, syncope or life-threatening arrhythmia as group II (43, 5, 2% vs 43, 13, 8%). AP was more frequently left lateral in group I (57%) than in group II (36%)(p < 0.001). AV re-entrant tachycardia, atrial fibrillation (AF), antidromic tachycardia were induced as frequently in group I (54, 18, 10%) as in group II (54, 27, 7%). Malignant forms (induced AF with RR intervals between preexcited beats < 250 ms in control state or < 200 ms after isoproterenol) were as frequent in group I (11.5%) as II (14%).
The frequency of unapparent preexcitation syndrome represents 11% of our population with anterograde conduction through an AP and could be underestimated. The risk to have a malignant form is as high as in patients with overt preexcitation syndrome in SR.
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¹: Dr. Garratt is a recipient of a British Heart Foundation Junior Research Fellowship.

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Use of intravenous adenosine in sinus rhythm as a diagnostic test for latent preexcitation

Abstract

Am J Cardiol

Am J Cardiol

Am J Cardiol

Prog Cardiovasc Dis

Am J Cardiol

Am Heart J

Lancet

Am J Cardiol

Am J Cardiol

Am J Cardiol

JACC

Am J Cardiol

Am Heart J

Electrophysiological characteristics of concealed bypass tracts: clinical and electrocardiographic correlates

Am J Cardiol