Adenosine Dose and Cardioversion in Pediatric Supraventricular Tachycardia: A Systematic Review and Meta-Analysis

Although adenosine is recommended as first-line therapy for pediatric supraventricular tachycardia (SVT), the optimal weight-based dose for reliable first-pass cardioversion remains uncertain. To evaluate the association between weight-based adenosine dosing and cardioversion probability in children with SVT. PubMed, Embase, Scopus, and the Cochrane Library were searched from inception through July 2025. Of 3,195 records identified, 9 observational studies including 480 patients and 1,369 intravenous adenosine bolus administrations met inclusion criteria. Two reviewers independently screened studies and extracted bolus-level cardio version data. Risk of bias was assessed with ROBINS-I and certainty of evidence with GRADE. Logit-transformed cardioversion proportions were pooled using a three-level random-effects model to account for clustering of multiple bolus administrations within studies. Successful cardioversion to sinus rhythm following an individual intravenous adenosine bolus. Conversion probability increased across prespecified weight-based dose categories: 25% (95% CI, 14%-40%) at doses < 100 µg/kg, 38% (95% CI, 31%-46%) at 100 µg/kg, 47% (95% CI, 39%-55%) at 150-225 µg/kg, and 59% (95% CI, 48%-69%) at 250-400 µg/kg. In the three-level model, overall conversion probability was 41% (95% CI, 35% to 47%). Increasing dose was associated with higher odds of cardioversion (β = 0.0054 per µg/kg; OR per 100 µg/kg, 1.72 [95% CI, 1.43 to 2.07]; P < .001), with residual heterogeneity primarily attributable to between-study variability. Higher weight-based adenosine doses were consistently associated with greater conversion probability across observational cohorts. These findings suggest that commonly used initial doses may underperform in many children and justify prospective trials evaluating mechanism-specific initial dosing strategies.