Intravenous Adenosine Reveals Intermittent Preexcitation by Direct and Indirect Effects on Accessory Pathway Conduction

In some patients with accessory pathways preexcitation occurs intermittently during sinus rhythm. In these patients the antegrade refractory period of the accessory pathway may either exceed the sinus cycle length under some circumstances, or conduction block in the accessory pathway may be variable. The ability of intravenous adenosine to unmask intermittent preexcitation was determined in patients with intermittent preexcitation but absent preexcitation at the time of study. Six patients undergoing assessment of the Wolff-Parkinson-White syndrome received incremental doses of intravenous adenosine (3, 6, and 12 mg). Adenosine administration was repeated in three patients after intravenous beta blockade (propranolol 0.2 mg/kg). Adenosine unmasked preexcitation in all patients. P delta intervals with preexcited beats were substantially shorter than resting PR intervals in all cases (range 40-80 msec shorter). In 4/6 patients preexcitation was seen early, coincident with the onset of atrioventricular nodal block. In 4/6 patients preexcitation was seen late during the secondary sinus tachycardia that follows the direct cardiac effects of adenosine. Two patients exhibited early preexcitation and late preexcitation. Beta blockade failed to prevent early preexcitation (2/2 patients) but abolished preexcitation related to sinus tachycardia (3/3 patients). Early preexcitation, coincident with the onset of AV nodal block, suggests a direct effect of adenosine on accessory pathway conduction. Late preexcitation, occurring during secondary sinus tachycardia, and abolished by beta blockade, suggests enhanced accessory pathway conduction due to sympathetic activation.