Adenosine versus intravenous calcium channel antagonists for tachycardia in adults

Holdgate A, Foo A

Published Online:

January 21, 2009

Supraventricular tachycardia (SVT)is a common abnormal rhythm of the heart resulting in a very rapid heart beat. This rhythm problem usually occurs in otherwise healthy people and common symptoms include palpitations, light headedness, and chest pain. Occasionally, SVT may also cause confusion or loss of consciousness. SVT can sometimes be treated with simple physical manoeuvres such as forced breath holding. When simple manoeuvres fail, supraventricular tachycardia can be treated in the Emergency department with a variety of different drugs. The two most commonly used drug types are adenosine and calcium channel antagonists (verapamil is the most frequently used drug in this class). This review compares the relative effectiveness and side effects of these two drugs.

Eight trials involving 577 patients were included in the review. Combined analysis of these trials showed no difference in the effectiveness of adenosine and verapamil in successfully treating supraventricular tachycardia, with an overall success rate of approximately 90% for both drugs. Adenosine took less time than verapamil to work, but when effective, both drugs worked within 15 minutes. Adenosine was associated with more side effects than verapamil, with approximately one in ten patients treated with adenosine experiencing chest pain, nausea, shortness of breath or headache, while these symptoms occurred in less than 1% of patients treated with verapamil. However these side effects lasted for only a short time, usually less than a few minutes. Very low blood pressure which required treatment was reported in three out of 166 patients treated with verapamil, while no patients treated with adenosine experienced low blood pressure.

Overall, both drugs appear to be similarly effective but adenosine is associated with a relatively high incidence of 'minor' side effects and verapamil is associated with infrequent 'major' side effects. None of the trials examined patient satisfaction with treatment or how long patients had to stay in hospital, and this somewhat limits the significance of the findings as these issues are probably most important in deciding which drug is the 'best' treatment.

Abstract (click to read)

Background:

Patients with paroxysmal supraventricular tachycardia frequently present to the Emergency Department. Where vagal manoeuvres fail, the two most commonly used drugs are adenosine and calcium channel antagonists. Both are known to be effective but both have a significant side-effect profile.

Objectives:

To examine the relative effects of adenosine and calcium channel antagonists and, if possible, to determine which is most appropriate for the management of supraventricular tachycardia.

Search strategy:

Studies were identified from The Cochrane Central Register of Controlled Trials (CENTRAL), Issue 3 2006, MEDLINE (1966 to June 2006), Pre-MEDLINE and EMBASE (1980 to June 2006). Bibliographies of identified studies were also examined. No language restrictions were applied.

Selection criteria:

Inclusion criteria: randomised trials comparing adenosine and a calcium channel antagonist in patients of any age with supraventricular tachycardia, where one of the defined outcomes was reported. Outcomes of interest were: reversion rate, mortality, time to reversion, rate of relapse, minor adverse events, major adverse events, length of hospital stay and patient satisfaction. Major adverse events were defined as cardiac arrest, prolonged hypotension, symptomatic bradycardia requiring treatment and acute cardiac failure. Minor adverse events were any other reported event.

Data collection and analysis:

Two reviewers independently checked the results of searches to identify relevant studies. Dichotomous outcomes were reported as Peto Odds ratios and continuous outcomes as weighted mean differences.

Main results:

Eight trials were identified. In the pooled analysis there was no significant difference in reversion rate or relapse rate between the two drugs. Time to reversion was slower for verapamil than adenosine in all studies that reported this outcome, but the data were not suitable for combining. Minor adverse events such as nausea, chest tightness, shortness of breath and headache were reported much more frequently in patients treated with adenosine with 10.8 % of patients reporting at least one of these events, compared with 0.6% of those treated with verapamil (OR 0.15, 95% CI 0.09 to 0.26, P<0.001). There was no significant difference in the rate of major adverse events between the two groups, although hypotension was reported exclusively in the verapamil treatment group (3/166 patients treated with verapamil, 0/171 treated with adenosine).

Authors' conclusions:

Adenosine and verapamil are both effective treatments for supraventricular tachycardia in the majority of patients. However, given the high incidence of minor but unpleasant side effects in patients treated with adenosine and the potential for hypotension with verapamil, patients should be fully informed of these risks prior to treatment.

This record should be cited as:

Holdgate A, Foo A. Adenosine versus intravenous calcium channel antagonists for the treatment of supraventricular tachycardia in adults. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD005154. DOI: 10.1002/14651858.CD005154.pub2

Assessed as up to date:

August 2, 2006

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Primary Review Group:

Heart Group

Health topics:

Heart & circulation > Arrythmias

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Adenosine versus intravenous calcium channel antagonists for tachycardia in adults

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