The clinical impact of ajmaline challenge in elderly patients with suspected atrioventricular conduction disease ☆ Giulio Conte ⁎, Moises Levinstein, Andrea Sarkozy, Juan Sieira, Carlo de Asmundis, Gian-Battista Chierchia, Giacomo Di Giovanni, Giannis Baltogiannis, Giuseppe Ciconte, Kristel Wauters, Gudrun Pappaert, Pedro Brugada Heart Rhythm Management Centre, UZ Brussel-VUB, Brussels, Belgium abstract article info Article history: Received 7 September 2013 Received in revised form 2 January 2014 Accepted 19 January 2014 Available online 24 January 2014 Keywords: Ajmaline Elderly Atrioventricular conduction disease Brugada syndrome Syncope Background: The effects and the safety of ajmaline challenge in elderly patients with suspected atrioventricular (AV) conduction disease have not been systematically investigated. The purpose of this study was to assess the response of intravenous administration of ajmaline in patients older than 75 years suspected to be affected by AV conduction disease with respect to unmask high-degree His-Purkinje block or the typical Brugada ECG pattern. Methods: Consecutive patients older than 75 years having undergone in our centre an electrophysiologic study with intravenous ajmaline administration were eligible for this study. Results: A total of 162 consecutive patients older than 75 years (84 males; mean age: 78 ± 4 years) were included. Ajmaline induced prolongation of the H–V interval up to 100 ms or more in 25 patients (15%). High degree His-Purkinje block was produced in 5 patients (3%). Moreover, ajmaline challenge unmasked a Brugada type 1 ECG in 12 patients (7%). No ventricular tachyarrhythmia was observed during the pharmacologic challenge and no severe side effects occurred. Among the study population, 56 (34%) and 6 patients (4%) underwent a PM and ICD implantation, respectively. For the patients with BS, a family screening was performed in a total of 37 individuals. Eighteen family members (48%) presented a positive ajmaline test and 1 (3%) a spontaneous Brugada type 1 ECG. Conclusions: Ajmaline challenge in the elderly is a safe procedure to unmask AV conduction disease and can lead to an unexpected diagnosis of BS. Although the clinical impact is obvious, the therapeutic management remains controversial. © 2014 Elsevier Ireland Ltd. All rights reserved. 1. Introduction The effects and the safety of ajmaline challenge in elderly patients with suspected atrioventricular (AV) conduction disease have not been systematically investigated. Electrophysiologic (EP) study is a useful tool to detect atrioventricular (AV) conduction abnormalities, although with low sensitivity [1–3]. Pharmacological challenge with intravenous administration of ajmaline has been proposed to increase its sensitivity to identify patients with syncope at higher risk of developing AV block [4–6]. Ajmaline, as a potent sodium channel blocker with short lasting half- life, is supposed to be the best agent able to amplify or unmask the diagnostic electrocardiographic (ECG) pattern of Brugada syndrome (BS) in the case of non-diagnostic basal ECG as compared to other antiarrhythmic drugs (AADs) [7,8]. BS is an inheritable syndrome characterized by coved-type ST-segment elevation in the right precordial leads (V1–3) and increased risk of sudden death in the absence of struc- tural heart disease [9]. The mean age of patients presenting with either symptomatic or asymptomatic BS has been reported to be in the fourth or fifth decade [10]. Although there is considerable literature on the prevalence and the characteristics of BS in adults, only case reports have been published and no systematic study has been carried out to describe the clinical features of the syndrome in the elderly [11,12]. Additionally, no generally accepted or evidence based guidelines are available for the therapeutic management of this particular population. The purpose of this study was to investigate the response to intra- venous administration of ajmaline in patients older than 75 years suspected to be affected by AV conduction disease with respect to unmask high-degree His-Purkinje block or the typical Brugada ECG pattern. In addition, the clinical impact as well as the safety of ajmaline challenge in the elderly was evaluated. 2. Methods 2.1. Study population All consecutive individuals older than 75 years having undergone in our centre an EP study with intravenous ajmaline administration for suspected AV conduction disturbances were included in this study. Indications for ajmaline challenge were an episode of International Journal of Cardiology 172 (2014) 423–427 ☆ All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. ⁎ Corresponding author at: Heart Rhythm Management Centre, UZ Brussel-VUB, Laarbeeklaan 101, 1090 Brussels, Belgium. Tel.: +32 2 4763038; fax: +32 2 477 6840. E-mail address: giulioconte.cardio@gmail.com (G. Conte). 0167-5273/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2014.01.103 Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard