Ajmaline Provocation Test

What is an ajmaline provocation test?

An ajmaline provocation test is a specific type of test that we use to diagnose a condition called Brugada syndrome. It is a bit different to most of our other tests because it involves giving you the drug ajmaline and seeing how your heart trace changes.

What is Brugada syndrome?

Brugada syndrome is a relatively rare, but potentially serious, hereditary condition of the heart. It is caused by defects in the tiny pores, or sodium channels, between cells in the heart muscle. These defects can disrupt the normal electrical system of the heart and cause heart rhythm changes (arrhythmias), which in some rare cases can be life threatening.

The diagnosis is made by recognising a specific pattern on your heart tracing. In some patients these changes are obvious and the diagnosis is clear as soon as you’ve had an ECG. But the ECG changes can be very subtle and, in some people, cannot be seen with a standard ECG. This can make diagnosing Brugada syndrome with a heart tracing alone difficult, and your doctors may use additional tests to help make a diagnosis. This may include a special ‘high leads’ ECG, an ambulatory ECG (a heart monitor worn for a prolonged period) or an ajmaline provocation test.

What does an ajmaline provocation test involve?

Ajmaline is a medicine which blocks the sodium channels in the heart muscle and allows the classic Brugada pattern to reveal itself if the syndrome is present.

During an ajmaline provocation test, ajmaline is given in a liquid form through a drip (cannula) into a vein. During this time, you are continuously monitored and ECG’s are taken at regular intervals to identify any changes. Ajmaline takes effect very quickly when given in this way, it also wears off quickly, so the test does not take a long time to complete but some monitoring afterward is required.

What are the risks and benefits of having the test?

The ajmaline provocation test is safe. However, as with any procedure, there are potential risks that you need to consider.

Benefits of having an ajmaline provocation test:

• Uncovering a diagnosis of Brugada syndrome means that the relevant, precautionary, lifestyle advice can be provided. Following these simple lifestyle measures can reduce the risk of serious arrhythmias associated with the condition.
• Knowing you have a diagnosis of Brugada syndrome allows your medical team to assess your risk related to the condition and make early interventions if there are concerns.
• For safety, first degree relatives would be advised to have screening for the condition if the ajmaline test was found to be positive. This is because Brugada syndrome is an inherited condition of the heart.

Common side effects include:

• Tingling
• Flushing
• Nausea
• Headache or feeling dizzy
• Taste disturbance such as a metallic taste
• Rash (Urticaria)

These side effects are usually very mild and pass very quickly after stopping the test.

Very rare adverse side effects:

• Altered liver function (cholestsatic jaundice)- this may result in yellowing of the skin and eyes as well as itching. This is likely to resolve by itself but may require blood tests to monitor liver function in the weeks after the test.
• Heart rhythm changes – in very rare circumstances, ajmaline can cause dangerous heart rhythm changes at the time of the infusion which may need urgent treatment. We call these heart rhythm changes ‘ventricular arrhythmias’, and the incidence of this is felt to be around 1 in 1000 worldwide. The test is carried out in a monitored environment with qualified staff who can provide treatment for this if necessary.

Other considerations:

• A positive test result may have implications for first degree relatives, as Brugada syndrome is a hereditary condition
• A positive test needs to be declared to the DVLA and when applying for certain types of insurance. Provided you have no symptoms, currently the DVLA will allow you to drive provided they have been notified.
• Interpretation of the test results can sometimes be challenging and false positives can occur, for this reason the patient history and all other test results are carefully considered when providing a diagnosis

How should I prepare for the test?

• If you take beta blockers, you should stop taking these three days prior to the test. If you have concerns about this ensure you discuss it with your cardiology team
• You should not take any medications which are advised against if you have Brugada syndrome, in the days leading up to your test. It would be best to discuss stopping any regular medications with your cardiology team
• You should fast from food and drinks for two hours prior to the test

What happens during the test?

• The procedure will take place on the cardiology, day-case ward at Leeds General Infirmary. This is ward L14, which is located on E floor of Jubilee wing. You should plan to be in hospital for approximately three hours, occasionally monitoring is needed for a longer period afterward.
• When you arrive, you should check in at the reception desk, here you will be asked to confirm some details and you will be provided with a patient wrist band.
• A cardiac nurse specialist will meet you and take you to a patient bay. The nurse will explain the procedure and discuss the risks and benefits before asking you to sign a consent form.
• Prior to the test you will be provided with a patient gown. You will have your weight checked (this guides the dose of ajmaline given), have your blood pressure checked and have a small tube (cannula) inserted into the back of your hand or arm.
• There will be two specialist nurses performing your test and sometimes a doctor may be present.
• You will have specialist ECG monitoring applied by attaching electrode stickers on the chest, legs and arms. This will be in place for the duration of the test and will be closely monitored for any changes.
• When you are ready and comfortable you will be given small doses of the ajmaline through your cannula, this will happen at one minute intervals until you have reached the maximum dose for your weight.
• This takes approximately 10 minutes but the test may be stopped early if there are changes to your ECG, in this event your nurse will explain why the test has been stopped.
• If Brugada pattern changes are seen the test will be stopped, however the test may also be stopped due to ECG changes which are unrelated to Brugada syndrome
• You will have ECG’s recorded every few minutes initially; the final ECG takes place 90 minutes after the test began. This is to check that the effects of the medication have worn off

What happens after the test?

• 30 minutes after the last dose of ajmaline, if you are well, continuous monitoring will be removed and you will be able to have something to eat and drink.
• 90 minutes after the last dose of ajmaline you will have a final ECG recorded to ensure any changes have returned to normal.
• If your final ECG has returned to what is normal for you and you are feeling well, the cannula will be removed from your arm and you will be advised to get dressed into your own clothes.
• If you are well you can drive after the procedure and can go about your usual activities.
• If you suffer any side effects related to the ajmaline provocation test you may be required to stay in hospital for monitoring overnight.
• The specialist nurse performing the test will discuss the results with you on the same day. Occasionally, the outcome may be difficult to interpret and your ECG may require further review by a consultant cardiologist.
• If you have a positive ajmaline provocation test the nurse will explain what this means in relation to why you were having the test. The nurse will also go through some lifestyle advice and give you some written information to take away. You will be given a plan for follow up in one of the consultant clinics and contact numbers for if you have concerns in the meantime.
• If you have a negative result, again the nurse will explain what this means in relation to the reason you were having the test. You will be given a plan for follow up and general recovery advice for when you get home.
• All results will also be communicated by letter.

Contact Information

Further Information

Further Information about Brugada syndrome and Ajmaline provocation testing can be found on the following websites: