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J Am Coll Cardiol, 2003; 41:93-98
© 2003 by the American College of Cardiology Foundation
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CLINICAL STUDY: CARDIAC ARRHYTHMIAS

Mechanism of syncope in patients with positive adenosine triphosphate tests

Paolo Donateo, MD*, Michele Brignole, MD*,*, Carlo Menozzi, MD{dagger}, Nicola Bottoni, MD{dagger}, Paolo Alboni, MD{ddagger}, Maurizio Dinelli, MD{ddagger}, Attilio Del Rosso, MD§, Francesco Croci, MD*, Daniele Oddone, MD*, Alberto Solano, MD* and Enrico Puggioni, MD*

* Ospedali del Tigullio, Lavagna, Italy
{dagger} Ospedale S. Maria Nuova, Reggio Emilia, Italy
{ddagger} Ospedale Civile, Cento, Italy
§ Ospedale S. Pietro Igneo, Fucecchio, Italy

Manuscript received May 24, 2002; revised manuscript received September 5, 2002, accepted September 13, 2002.

* Reprint requests and correspondence: Dr. Michele Brignole, Department of Cardiology, Ospedali Riuniti, I-16032 Lavagna, Italy.
mbrignole{at}ASL4.liguria.it

OBJECTIVES: We prospectively evaluated the mechanism of syncope in patients with positive adenosine triphosphate (ATP) tests (defined as the induction of atrioventricular [AV] block with a ventricular pause ≥6 s after an intravenous bolus of 20 mg ATP).

BACKGROUND: Patients with unexplained syncope tend to have more positive ATP tests results than those without syncope.

METHODS: An implantable loop recorder (ILR) was inserted in 36 ATP-positive patients (69 ± 10 years; 22 women; median of 6 syncopal episodes); 15 of them also had a positive response to tilt testing.

RESULTS: During the follow-up of 18 ± 9 months, 18 patients (50%) had syncopal recurrence and 16 (44%) had an electrocardiographically documented episode: AV block (n = 3: paroxysmal in 2 and permanent in 1), AV block followed by sinus arrest (n = 1), sinus arrest (n = 5), sinus bradycardia <40 beats/min (n = 2), normal sinus rhythm (n = 2), sinus tachycardia (n = 1), rapid atrial fibrillation (n = 1), and ectopic atrial tachycardia (n = 1). Bradycardia was documented in a total of 11 cases (69%), and a long ventricular pause (4 to 29 s) was present in eight cases (50%). All three patients with ILR-documented AV block had previously had a negative tilt test, whereas seven of eight with ILR-documented sinus bradycardia or sinus arrest had previously had a positive tilt test.

CONCLUSIONS: In patients with adenosine-sensitive syncope, the mechanism of syncope is heterogeneous, although bradycardia is the most frequent finding. Adenosine triphosphate–induced AV block predicts AV block as the mechanism of spontaneous syncope in only a few tilt-negative patients.

Abbreviations and Acronyms
  ATP
  adenosine triphosphate
  AV
  atrioventricular
  ECG
  electrocardiogram
  ILR
  implantable loop recorder




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