The diagnostic role of pharmacological provocation testing in cardiac electrophysiology: a clinical consensus statement of the European Heart Rhythm Association and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC, the ESC Working Group on Cardiovascular Pharmacotherapy, the Association of European Paediatric and Congenital Cardiology (AEPC), the Paediatric & Congenital Electrophysiology Society (PACES), the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), and the Latin American Heart Rhythm Society (LAHRS).

Peter Damman, Lia Crotti, Eric Schulze-Bahr, Jacob Tfelt-Hansen, Juan Carlos Kaski, Dobromir Dobrev, Giulio Conte, Pieter G Postema, Kristina Haugaa, Elijah R Behr, Bode Ensam, Alberto Alfie, Cecilia M Gonzalez Corcia, Silvia Priori, Alejandro Cuesta, Andrew Krahn, Ulrich Krause, Fabrizio Drago, Marina Cerrone, Bo Gregers Winkel, Colin Berry, Koonlawee Nademanee, Vincent Probst, Wataru Shimizu, Rafik Tadros, Christian Veltmann, Pier D Lambiase, Katja E Odening, Georgia Sarquella-Brugada, Carlo Napolitano, Elena Arbelo, Arthur Wilde, Christian Wolpert

Journal: Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology 2025;27(4):

PMID: 40165484

Abstract

The pharmacological provocation test is a pivotal tool in cardiac electrophysiology for the diagnosis of potential causes of sudden cardiac death, sudden cardiac arrest (SCA), arrhythmias, symptoms, or ECG abnormalities. The 2022 European Society of Cardiology Guidelines for the Treatment of Ventricular Arrhythmias and Prevention of Sudden Cardiac Death offered guidance on provocation testing but did not describe the indications and requirements in depth. This clinical consensus statement, led by the European Heart Rhythm Association and approved by major international stakeholders, aims to advise the general cardiologist and the arrhythmia expert who to test and when, where, and how to do it. The statement focuses on current practice for the diagnosis of subclinical arrhythmia syndromes and the causes of SCA, building upon the recommendations of the Guidelines. We address the sodium channel blocker provocation test for patients suspected of Brugada syndrome as well as the use of epinephrine, isoproterenol, adenosine, ergonovine, and acetylcholine.

© The Author(s) 2025. Published by Oxford University Press on behalf of the European Society of Cardiology.

Address: Cardiovascular and Genomics Research Institute, School of Health and Medical Sciences, City St. George's, University of London, Cranmer Terrace, London, SW17 0RE, UK.; Cardiology Care Group, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK.; Mayo Clinic Healthcare, 15 Portland Place, London, W1B 1PT, UK.; Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart.; Cardiovascular and Genomics Research Institute, School of Health and Medical Sciences, City St. George's, University of London, Cranmer Terrace, London, SW17 0RE, UK.; University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK.; Electrophysiology Section, Cardiology Division, Hospital Nacional Profesor Alejandro Posadas, Moron, Argentina.; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart.; Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.; Institut d'Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain.; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.; Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK.; The Leon Charney Division of Cardiology, New York University Grossmann School of Medicine, New York, NY, USA.; Division of Cardiology, Cardiocentro Ticino Institute Ente Ospedaliero Cantonale, Lugano, Switzerland.; Istituto Auxologico Italiano, IRCCS, Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, Milan, Italy.; Department of Medicine and Surgery, Università Milano-Bicocca, Milan, Italy.; Department of Cardiology, Sainte-Justine University Hospital Center, Montreal, QC, Canada.; Cardiovascular and Genomics Research Institute, School of Health and Medical Sciences, City St. George's, University of London, Cranmer Terrace, London, SW17 0RE, UK.; Department of Medicine, Center of Excellence in Arrhythmia Research, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart.; Department of Clinical Cardiology, Heart Centre, Amsterdam University Medical Centre, Location AMC, Amsterdam, The Netherlands.; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart.; Molecular Cardiology Unit, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy.; Department of Molecular Medicine, University of Pavia, Pavia, Italy.; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart.; Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du Thorax, Nantes, France.; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart.; Arrhythmias, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain.; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart.; Institute for Genetics of Heart Diseases, University Hospital Münster, Münster, Germany.; Department of Medicine, Montreal Heart Institute, Montreal, QC, Canada.; Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart.; Department of Forensic Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.; Department of Cardiology, Kliniken Ludwigsburg Bietigheim gGmbH, Ludwigsburg, Germany.; Servicio Electrofisiología, Unidad Académica Cardiología, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay.; Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands.; Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany.; Department of Medicine and Research Center, Montreal Heart Institute and Université de Montréal, Montreal, QC, Canada.; Department of Integrative Physiology, Baylor College of Medicine, Houston, TX, USA.; Paediatric Cardiology and Cardiac Arrhythmias Complex Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.; Department of Cardiology, ProCardio Center for Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway.; Faculty of medicine, University of Oslo, Oslo, Norway.; Division of Cardiology, University of British Columbia, Vancouver, BC, Canada.; Department of Pediatric Cardiology, University Medical Center Göttingen, Georg-August-University, Intensive Care Medicine and Neonatology, Göttingen, Germany.; Dept of Cardiology, Institute of Cardiovascular Science UCL, Barts Heart Centre, London, UK.; Department of Molecular Medicine, University of Pavia, Pavia, Italy.; Molecular Cardiology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy.; Department of Cardiology and Department of Physiology, University Hospital Bern (Inselspital) and University of Bern, Bern, Switzerland.; Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan.; New Tokyo Hospital, Matsudo, Japan.; Heart Center Bremen, Electrophysiology Bremen, Bremen, Germany.

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