Approach to adenosine dosing in stable adults with suspected supraventricular tachyarrhythmia

This figure summarizes the initial dosing, administration, and need for repeat dosing of adenosine in a hemodynamically stable adult with suspected AV node-dependent SVT. Adenosine can be used as a diagnostic aid to identify the underlying rhythm or as a therapy to terminate SVTs that rely on AV node conduction. AV node-dependent SVTs include AV nodal reentrant tachycardia (AVNRT) and AV reentrant (or reciprocating) tachycardia (AVRT). The management of suspected AV node-dependent SVT in hemodynamically stable adults commonly starts with a trial of 1 or more vagal maneuvers prior to proceeding to adenosine therapy. If the patient has hemodynamically unstable SVT, cardioversion is indicated. Refer to UpToDate content for details on management of SVTs.

AV: atrioventricular; SVT: supraventricular tachycardia; IV: intravenous; ACC: American College of Cardiology; AHA: American Heart Association; HRS: Heart Rhythm Society; ECG: electrocardiogram.

* Lower adenosine doses are indicated in certain clinical settings. If central venous administration is performed, the initial adenosine dose is 3 mg; if needed (SVT persists and there is no AV block), the dose may be increased to 6 mg and then 9 mg for subsequent doses. For heart transplant recipients, the initial adenosine dose is 1 mg; if needed (SVT persists and there is no AV block), the dose may be increased to 2 mg and then 3 mg for subsequent doses.

¶ An 18 mg dose is more likely to be required to produce AV block in patients with a body weight >70 kg, particularly in those weighing >110 kg.^[1] When a third dose is indicated, an alternative approach is to administer 12 mg (instead of 18 mg) as described in the 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients with Supraventricular Tachycardia.^[2]

Δ SVT termination in response to adenosine includes SVT termination closely followed by SVT recurrence.

◊ Refer to UpToDate content on treatment of SVT for dosing of second-line AV nodal blockers. If the SVT persists despite second-line AV nodal blocker therapy, electrical cardioversion is performed, as discussed in UpToDate content on treatment of SVT.

§ SVTs that are not AV node dependent include atrial flutter, atrial fibrillation, and atrial tachycardia. When AV nodal block is induced by adenosine, the ECG may reveal atrial activity diagnostic of these rhythms.

References:

Prabhu S, Mackin V, McLellan AJA, et al. Determining the optimal dose of adenosine for unmasking dormant pulmonary vein conduction following atrial fibrillation ablation: Electrophysiological and hemodynamic assessment. DORMANT-AF study. J Cardiovasc Electrophysiol 2017; 28:13.
Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2016; 133:e506.

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Approach to adenosine dosing in stable adults with suspected supraventricular tachyarrhythmia