Pre-excited atrial fibrillation triggered by intravenous adenosine: a commonly used drug with potentially life-threatening adverse effects

Turley, Andrew; Murray, Suzanne; Thambyrajah, Jeetendra

doi:10.1136/emj.2007.051227

Cited by 22 publications

(14 citation statements)

References 8 publications

(3 reference statements)

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“…Of note, adenosine can precipitate ventricular tachycardia in preexcitation syndromes (e.g. Wolff-Parkinson-White) by rapid anterograde conduction of AF via the accessory pathway [11]. After cardiac surgery, an atrial lead ECG from the pacemaker wire can be helpful.…”

Section: Resultsmentioning

confidence: 99%

“…Increased sympathetic tone and systemic inflammation also play a central role in maintaining AF [10, 34]. Inflammation may lead to atrial myocarditis with subsequent electrical and structural atrial changes, resulting in the initiation and maintenance of AF [11, 35]. Because AF triggers AF, paroxysmal AF might progress to persistent and permanent AF [1, 36].…”

Section: Resultsmentioning

confidence: 99%

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Management of Atrial Fibrillation in Critically Ill Patients

Arrigo

Béttex

Rudiger

2014

Critical Care Research and Practice

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Atrial fibrillation (AF) is common in ICU patients and is associated with a two- to fivefold increase in mortality. This paper provides a reappraisal of the management of AF with a special focus on critically ill patients with haemodynamic instability. AF can cause hypotension and heart failure with subsequent organ dysfunction. The underlying mechanisms are the loss of atrial contraction and the high ventricular rate. In unstable patients, sinus rhythm must be rapidly restored by synchronised electrical cardioversion (ECV). If pharmacological treatment is indicated, clinicians can choose between the rate control and the rhythm control strategy. The optimal substance should be selected depending on its potential adverse effects. A beta-1 antagonist with a very short half-life (e.g., esmolol) is an advantage for ICU patients because the effect of beta-blockade on cardiovascular stability is unpredictable in those patients. Amiodarone is commonly used in the ICU setting but has potentially severe cardiac and noncardiac side effects. Digoxin controls the ventricular response at rest, but its benefit decreases in the presence of adrenergic stress. Vernakalant converts new-onset AF to sinus rhythm in approximately 50% of patients, but data on its efficacy and safety in critically ill patients are lacking.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Management of Atrial Fibrillation in Critically Ill Patients

Arrigo

Béttex

Rudiger

2014

Critical Care Research and Practice

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“…Nevertheless, AF can be effectively induced in patients in the electrophysiology laboratory using a variety of techniques including isoproterenol, 7 adenosine, 8 or rapid pacing. 7 However, the profibrillatory effects 9 and ionic mechanisms 10 of these interventions are incompletely understood.…”

Section: Introductionmentioning

confidence: 99%

Mechanisms of Human Atrial Fibrillation Initiation

Krummen

Bayer

et al. 2012

Circ: Arrhythmia and Electrophysiology

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Background Mechanisms of atrial fibrillation (AF) initiation are incompletely understood. We hypothesized that rate-dependent changes (restitution) in action potential duration (APD) and activation latency are central targets for clinical interventions that induce AF. We tested this hypothesis using clinical experiments and computer models. Methods and Results In 50 patients (20 persistent, 23 paroxysmal AF, 7 controls), we used monophasic action potential catheters to define left atrial APD restitution, activation latency and AF incidence from premature extrastimuli. Isoproterenol (n=14), adenosine (n=10), or rapid pacing (n=36) were then initiated to determine impact on these parameters. Compared with baseline in AF patients, isoproterenol and rapid pacing decreased activation latency (64±14vs 31±13 vs 24±14 ms, p<0.05), steepened maximum APD restitution slope (0.8±0.7 vs 1.7±0.5 vs 1.1±0.5, p<0.05), and increased AF incidence (12% vs 64% vs 84%, p<0.05). Conversely, adenosine shortened APD (p<0.05), yet increased activation latency (86±27 ms, p=0.002) so that maximum APD restitution slope did not steepen (1.0±0.5, p=NS) and AF incidence was unchanged (10%, p=NS). In controls, no intervention steepened APD restitution or initiated AF. Computational modeling revealed that isoproterenol steepened APD restitution by increased ICaL and decreased activation latency via enhanced IKr inactivation, while rapid pacing steepened APD restitution via increased IK1. Conclusions Steep APD restitution is a common pathway for AF initiation by isoproterenol and tachycardia, via reduced activation latency that enables engagement of steep APD restitution at rapid rates. Modeling suggests AF initiation from each intervention uses distinct ionic mechanisms. This insight may help design interventions to prevent AF.

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“…Case studies have reported hemodynamic instability due to a rapid ventricular response from adenosine-induced AF in patients with accessory pathways. [16, 17] …”

Section: Cardiovascular Drugsmentioning

confidence: 99%

Drug-Induced Atrial Fibrillation

Kaakeh

Overholser

Lopshire

et al. 2012

Drugs

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Atrial fibrillation (AF) is a common cardiac arrhythmia that is associated with severe consequences, including symptoms, hemodynamic instability, increased cardiovascular mortality, and stroke. While other arrhythmias such as torsades de pointes and sinus bradycardia are more typically thought of as drug-induced, AF may also be precipitated by drug therapy, although ascribing causality to drug-associated AF is more difficult than with other drug-induced arrhythmias. Drug-induced AF is more likely to occur in patients with risk factors and comorbidities that commonly coexist with AF, such as advanced age, alcohol consumption, family history of AF, hypertension, thyroid dysfunction, sleep apnea, and heart disease. New-onset AF has been associated with cardiovascular drugs such as adenosine, dobutamine, and milrinone. In addition, medications such as corticosteroids, ondansetron, and antineoplastic agents such as paclitaxel, mitoxantrone, and anthracyclines have been reported to induce AF. Whether bisphosphonate drugs are associated with new onset AF remains controversial and requires further study. The potential contribution of specific drug therapy should be considered when patients present with new onset AF.

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Pre-excited atrial fibrillation triggered by intravenous adenosine: a commonly used drug with potentially life-threatening adverse effects

Cited by 22 publications

References 8 publications

Management of Atrial Fibrillation in Critically Ill Patients

Management of Atrial Fibrillation in Critically Ill Patients

Mechanisms of Human Atrial Fibrillation Initiation

Drug-Induced Atrial Fibrillation

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