Adenosine - All you need to know !!!

 

🫀 Mechanism of Action of Adenosine – Explained Clearly

Adenosine is one of the most fascinating drugs in cardiology — a molecule that literally stops the heart for a moment to save it. Despite its short half-life (less than 10 seconds!), its physiological and therapeutic effects are profound. Let’s break down how this tiny nucleoside exerts such dramatic actions.

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💊 What is Adenosine?

Adenosine is an endogenous purine nucleoside — a naturally occurring compound in the body derived from the breakdown of ATP (adenosine triphosphate). It plays roles in energy transfer, cell signaling, and modulation of cardiac and vascular function.

Clinically, adenosine is used mainly for:

Termination of paroxysmal supraventricular tachycardia (PSVT)

Diagnosis of tachyarrhythmias during electrophysiological testing

Assessment of coronary blood flow reserve in stress testing

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⚙️ Mechanism of Action

Adenosine acts through specific adenosine receptors located on cardiac and vascular tissues. The main subtypes involved are A1 and A2A receptors.

1. A1 Receptor (Cardiac Effects)

Found mainly in the SA node, AV node, and atrial tissue.

Activation of A1 receptors → stimulates Gi protein → inhibits adenylyl cyclase → ↓ cAMP levels.

This leads to:

Opening of inward rectifier K⁺ channels (IK-Ado) → hyperpolarization of nodal cells.

Reduced calcium influx through L-type Ca²⁺ channels → decreased conduction and automaticity.

🫧 Result:

Slows AV nodal conduction (negative dromotropy)

Decreases SA nodal firing rate (negative chronotropy)

Can transiently block AV conduction, which is the therapeutic mechanism used to terminate AVNRT or AVRT.

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2. A2A Receptor (Vascular Effects)

Present in vascular smooth muscle, especially in coronary vessels.

Activation → Gs protein stimulation → increased cAMP → smooth muscle relaxation.

🩸 Result:

Vasodilation, especially coronary vasodilation, which helps in myocardial perfusion imaging and coronary flow assessment.

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⚡ The Famous “Adenosine Pause”

When adenosine is administered intravenously (usually 6–12 mg rapid IV push), patients often experience a few seconds of asystole or AV block.

This is a transient electrophysiological pause — a reflection of the drug’s effect on the AV node — and is typically self-limited due to rapid degradation by adenosine deaminase in blood and tissues.

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⏱️ Pharmacokinetics in a Flash

Onset: Within seconds

Half-life: < 10 seconds

Metabolism: Rapid uptake by RBCs and endothelial cells; deaminated to inosine

Elimination: Non-renal; enzymatic degradation

Because of its ultra-short half-life, continuous ECG monitoring is essential during administration.

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🚑 Clinical Summary

Effect Mechanism Clinical Use

AV nodal block A1 receptor activation → ↓ cAMP → ↓ Ca²⁺ influx Termination of AVNRT/AVRT

Vasodilation A2A receptor activation → ↑ cAMP → smooth muscle relaxation Coronary flow reserve testing

Transient bradycardia/asystole SA/AV node suppression Diagnostic in SVTs

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⚠️ Precautions

Avoid in 2° or 3° AV block, sick sinus syndrome, or severe asthma (can trigger bronchospasm).

May interact with theophylline (antagonizes effect) and dipyridamole (potentiates effect).

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🧠 Quick Recap

Adenosine = “Natural Heart Reset”

A1 → AV nodal suppression → Stops reentry tachycardia

A2A → Vasodilation → Useful for perfusion imaging

Rapid onset, ultrashort action, and complete reversibility

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📌 Key Takeaway

Adenosine’s power lies in its simplicity — a naturally occurring molecule that can pause the heart safely to restore rhythm. Its ability to selectively block AV nodal conduction without lasting effects makes it a cornerstone in emergency and diagnostic cardiology.

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