Sick sinus syndrome: Difference between revisions
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*Also known as sinus dysfunction, sinoatrial node disease, and tachycardia-bradycardia syndrome (a specific variant) | *Also known as sinus dysfunction, sinoatrial node disease, and tachycardia-bradycardia syndrome (a specific variant) | ||
*Collection of signs or symptoms that indicate sinus node dysfunction<ref>Semelka, M et Al. Sick Sinus Syndrome: A Review. Am Fam Physician. 2013 May 15;87(10):691-696. http://www.aafp.org/afp/2013/0515/p691.html</ref> | *Collection of signs or symptoms that indicate sinus node dysfunction<ref>Semelka, M et Al. Sick Sinus Syndrome: A Review. Am Fam Physician. 2013 May 15;87(10):691-696. http://www.aafp.org/afp/2013/0515/p691.html</ref> | ||
*May present as bradycardia, tachycardia, or alternating bradycardia and tachycardia | *May present as [[bradycardia]], [[tachycardia]], or alternating bradycardia and tachycardia | ||
**50% have alternating bradycardia and tachycardia (i.e. tachycardia-bradycardia syndrome) | **50% have alternating bradycardia and tachycardia (i.e. tachycardia-bradycardia syndrome) | ||
| Line 8: | Line 8: | ||
*Intrinsic: | *Intrinsic: | ||
**Degenerative fibrosis | **Degenerative fibrosis | ||
**Infiltrative disease process | **Infiltrative disease process (e.g. [[amyloidosis]]) | ||
**Ion channel dysfunction | **Ion channel dysfunction | ||
**SA node remodeling | **SA node remodeling | ||
**[[Myocardial ischemia]] | |||
*Extrinsic: | *Extrinsic: | ||
**Pharmacologic | **Pharmacologic | ||
| Line 18: | Line 19: | ||
==Clinical Features== | ==Clinical Features== | ||
*Syncope or | *[[Syncope]] or presyncope (50%) | ||
*Palpitations | *[[Palpitations]] | ||
*Fatigue | *[[Fatigue]] | ||
*Generalized weakness | *Generalized [[weakness]] | ||
*Dyspnea | *[[Dyspnea]] | ||
*Angina | *[[Angina]] | ||
*Disturbed sleep | *Disturbed sleep | ||
*Confusion | *[[Confusion]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{ | {{Tachycardia (narrow) DDX}} | ||
{{Symptomatic bradycardia}} | {{Symptomatic bradycardia}} | ||
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==Management== | ==Management== | ||
* | *Remove extrinsic factors and/or pacemakers | ||
**Pacemakers do not reduce mortality, only decrease symptoms | **Pacemakers do not reduce mortality, only decrease symptoms | ||
*Consider reversible causes e.g. treat [[hyperkalemia]] or [[hypokalemia]] | |||
*[[Atropine]] for bradycardia, progress to catecholamine or pacing | |||
*consider [[aminophylline]], which inhibits suppressive effects of adenosine on the SA node in: <ref> Kusumoto FM, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019 Aug 20;74(7):e51-e156 </ref> | |||
**Acute inferior [[MI]] with 2nd or 3rd degree AV block; 250mv IV bolus | |||
**Heart transplant: 6mg/kg in 100-200mL of IV fluid over 20-30 minutes | |||
**Spinal cord injury: 6mg/kg in 100-200mL of IV fluid over 20-30 minutes | |||
==Disposition== | ==Disposition== | ||
| Line 43: | Line 50: | ||
==Complications== | ==Complications== | ||
*(50%) Tachy-brady syndrome with atrial fibrillation or atrial flutter | *(50%) Tachy-brady syndrome with [[atrial fibrillation]] or [[atrial flutter]] | ||
*(50%) AV block | *(50%) [[AV block]] | ||
==See Also== | ==See Also== | ||
Latest revision as of 16:12, 26 September 2019
Background
- Also known as sinus dysfunction, sinoatrial node disease, and tachycardia-bradycardia syndrome (a specific variant)
- Collection of signs or symptoms that indicate sinus node dysfunction[1]
- May present as bradycardia, tachycardia, or alternating bradycardia and tachycardia
- 50% have alternating bradycardia and tachycardia (i.e. tachycardia-bradycardia syndrome)
Causes
- Intrinsic:
- Degenerative fibrosis
- Infiltrative disease process (e.g. amyloidosis)
- Ion channel dysfunction
- SA node remodeling
- Myocardial ischemia
- Extrinsic:
- Pharmacologic
- Metabolic/electrolyte disturbance
- Autonomic dysfunction
- Obstructive sleep apnea
Clinical Features
- Syncope or presyncope (50%)
- Palpitations
- Fatigue
- Generalized weakness
- Dyspnea
- Angina
- Disturbed sleep
- Confusion
Differential Diagnosis
Narrow-complex tachycardia
- Regular
- AV Node Independent
- Sinus tachycardia
- Atrial tachycardia (uni-focal or multi-focal)
- Atrial fibrillation
- Atrial flutter
- Idiopathic fascicular left ventricular tachycardia
- AV Node Dependent
- AV Node Independent
- Irregular
- Multifocal atrial tachycardia (MAT)
- Sinus tachycardia with frequent PACs, PJCs, PVCs
- Atrial fibrillation
- Atrial flutter with variable conduction
- Digoxin Toxicity
Symptomatic bradycardia
- Cardiac
- Inferior MI (involving RCA)
- Sick sinus syndrome
- Neurocardiogenic/reflex-mediated
- Increased ICP
- Vasovagal reflex
- Hypersensitive carotid sinus syndrome
- Intra-abdominal hemorrhage (i.e. ruptured ectopic)
- Metabolic/endocrine/environmental
- Hyperkalemia
- Hypothermia (Osborn waves on ECG)
- Hypothyroidism
- Hypoglycemia (neonates)
- Toxicologic
- Infectious/Postinfectious
- Other
Evaluation
- ECG identification, inpatient telemetry, outpatient Holter monitoring, event monitoring, loop monitoring
- ECG frequently negative for findings early in disease course
Management
- Remove extrinsic factors and/or pacemakers
- Pacemakers do not reduce mortality, only decrease symptoms
- Consider reversible causes e.g. treat hyperkalemia or hypokalemia
- Atropine for bradycardia, progress to catecholamine or pacing
- consider aminophylline, which inhibits suppressive effects of adenosine on the SA node in: [2]
- Acute inferior MI with 2nd or 3rd degree AV block; 250mv IV bolus
- Heart transplant: 6mg/kg in 100-200mL of IV fluid over 20-30 minutes
- Spinal cord injury: 6mg/kg in 100-200mL of IV fluid over 20-30 minutes
Disposition
- Admit
Complications
- (50%) Tachy-brady syndrome with atrial fibrillation or atrial flutter
- (50%) AV block
See Also
External Links
References
- ↑ Semelka, M et Al. Sick Sinus Syndrome: A Review. Am Fam Physician. 2013 May 15;87(10):691-696. http://www.aafp.org/afp/2013/0515/p691.html
- ↑ Kusumoto FM, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019 Aug 20;74(7):e51-e156