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Diagnosis and Treatment of Sick Sinus Syndrome -- American Diagnosis and Treatment of Sick Sinus Syndrome VICTOR ADÁN, M.D., Angel Medical Center, Franklin, North Carolina LOREN A. CROWN, M.D., University of Tennessee Health Sciences Center, Covington, Tennessee Sick sinus syndrome comprises a variety of conditions involving sinus node dys- function and commonly affects elderly persons. While the syndrome can have many O A patient informa- causes, it usually is idiopathic. Patients may experience syncope, pre-syncope, pal- tion handout on sick pitations, or dizziness; however, they often are asymptomatic or have subtle or sinus syndrome, writ- ten by the authors of nonspecific symptoms. Sick sinus syndrome has multiple manifestations on electro- this article, is provided cardiogram, including sinus bradycardia, sinus arrest, sinoatrial block, and alternat- on page 1738. ing patterns of bradycardia and tachycardia (bradycardia-tachycardia syndrome). Diagnosis of sick sinus syndrome can be difficult because of its nonspecific symp- toms and elusive findings on electrocardiogram or Holter monitor. The mainstay of treatment is atrial or dual-chamber pacemaker placement, which generally provides effective relief of symptoms and lowers the incidence of atrial fibrillation, throm- boembolic events, heart failure, and mortality, compared with ventricular pace- makers. (Am Fam Physician 2003;67:1725-32,1738. Copyright©2003 American Acad- emy of Family Physicians) ick sinus syndrome is a generalized abnormality of cardiac impulse Etiology formation that may be caused by Most cases of sick sinus syndrome are idio- an intrinsic disease of the sinus pathic, and the cause can be multifactorial node that makes it unable to per- (Table 1).3 Degenerative fibrosis of nodal tis- Sform its pacemaking function, or by extrinsic sue is the most common cause of intrinsic causes.1 Abnormalities encompassed in this changes in the sinoatrial node that lead to sick syndrome include sinus bradycardia, sinus sinus syndrome. Certain conditions can cause arrest or exit block, combinations of sino- these intrinsic changes.3,5,6 There also are atrial and atrioventricular nodal conduction extrinsic causes of sinus node dysfunction and disturbances, and atrial tachyarrhythmias. conditions that can cause this problem in chil- Sick sinus syndrome is not a disease with a dren (Table 1).3 single etiology and pathogenesis but, rather, a Coronary artery disease may coexist with collection of conditions in which the electro- sick sinus syndrome in a significant number of cardiogram (ECG) indicates sinus node dys- patients, although it is not considered a major function.2 cause of the syndrome. It is unclear whether Sick sinus syndrome is characterized by inflammation, sinus node ischemia, or local sinus node dysfunction with an atrial rate autonomic neural effects lead to the develop- inappropriate for physiologic requirements. ment of sick sinus syndrome in patients with Although the condition is most common in myocardial infarction. Sinus node dysfunction the elderly, it can occur in persons of all ages, usually is temporary when it follows an acute including neonates.3 The mean age of pa- myocardial infarction. Uncommonly, chronic tients with this condition is 68 years, and ischemia may cause fibrosis and lead to symp- both sexes are affected approximately equally.4 toms of sick sinus syndrome for months to The syndrome occurs in one of every 600 car- years after myocardial infarction. diac patients older than 65 years and may account for 50 percent or more of perma- Clinical Manifestations nent pacemaker placements in the United Patients with sick sinus syndrome often States.5 are asymptomatic or have symptoms that are APRIL 15, 2003 / VOLUME 67, NUMBER 8 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1725 mild and nonspecific7 (Table 2).3 Symptoms TABLE 1 are related to the decreased cardiac output Causes of Sick Sinus Syndrome that occurs with the bradyarrhythmias or tachyarrhythmias.3 Most of the symptoms Intrinsic causes Extrinsic causes are caused by decreased cerebral perfusion, Amyloidosis Cholinesterase deficiency (suggested) and 50 percent of patients have syncope or Arteritis Hyperkalemia pre-syncope.5 Cardiomyopathies Hypoxia Symptoms, which may have been present Chagas’ disease Pharmacologic agents for months or years, can include syncope, Collagen vascular disease Digitalis palpitations, and dizziness, as well as symp- Diphtheria Calcium channel blockers Familial sinoatrial node disorders Beta blockers toms caused by the worsening of conditions Fatty replacement Sympatholytic agents such as congestive heart failure, angina pec- 8 Friedreich’s ataxia Antiarrhythmics toris, and cerebral vascular accident. Periph- Hemochromatosis Toxins eral thromboembolism and stroke, which Idiopathic degenerative fibrotic Pediatric causes can occur in the presence of bradycardia- infiltration* Congenital abnormalities tachycardia syndrome (alternating brady- Ischemia/infarction Sinoatrial nodal artery deficiency arrhythmias and tachyarrhythmias), may be Leukemia related to dysrhythmia-induced emboli.3 A Metastatic disease slow heart rate in the presence of fever, left Muscular dystrophy ventricular failure, or pulmonary edema may Myocarditis 2,9 Pericarditis be suggestive of sick sinus syndrome. Asso- Rheumatic heart disease ciated tachycardia may cause flushing of the Sarcoidosis face, pounding of the heart, and retrosternal Surgical injury pressure.10 Other symptoms include irritabil- ity, nocturnal wakefulness, memory loss, *—Most common intrinsic cause. errors in judgment, lethargy, lightheaded- 2,11 3 Adapted with permission from Wahls SA. Sick sinus syndrome. Am Fam Physician ness, and fatigue (Table 2). More subtle 1985;31:118. symptoms include mild digestive distur- bances, periodic oliguria or edema, and mild intermittent dyspnea.2 ECG Manifestations Sick sinus syndrome can produce a variety TABLE 2 of ECG manifestations consisting of atrial Symptoms of Sick Sinus Syndrome bradyarrhythmias, atrial tachyarrhythmias, and alternating bradyarrhythmias and Central nervous system Cardiovascular system Other tachyarrhythmias7 (Table 3).3 Supraventric- Dementia Angina pectoris Digestive disturbances ular bradyarrhythmias may include sinus Irritability Arterial thromboemboli Dizziness bradycardia, sinus arrest with or without Lethargy Cerebrovascular Errors in judgment junctional escape, sinoatrial exit block, Lightheadedness accident Facial flushing Memory loss Congestive heart failure Fatigue ectopic atrial bradycardia, and atrial fibrilla- Nocturnal wakefulness Palpitations Oliguria tion with slow ventricular response. The Syncope or pre-syncope sinus bradycardia that occurs in patients with sick sinus syndrome is inappropriate Adapted with permission from Wahls SA. Sick sinus syndrome. Am Fam Physician and not caused by medications.2,5 The sino- 1985;31:123. atrial exit block that occurs in patients with sick sinus syndrome may demonstrate a 1726 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 67, NUMBER 8 / APRIL 15, 2003 Sick Sinus Syndrome TABLE 3 The treatment of choice for symptomatic bradyarrhythmias Arrhythmias Associated in patients with sick sinus syndrome is the placement of a with Sick Sinus Syndrome pacemaker. Atrial bradyarrhythmias Sinus bradycardia Sinus arrest (with or without junctional escape) Mobitz type I block (Wenckebach block) Sinoatrial exit block and a Mobitz type II block.2 The ECG may Mobitz type I block (Wenckebach block) reveal a long pause following cardioversion Mobitz type II block of atrial tachyarrhythmias, and a greater- Ectopic atrial bradycardia Atrial fibrillation with slow ventricular response than three-second pause following carotid 5 Greater-than 3-second pause following carotid massage. Sixty percent of patients have massage tachyarrhythmias.8 Long pause following cardioversion of atrial Supraventricular tachyarrhythmias that tachyarrhythmias occur in patients with sick sinus syndrome Atrial tachyarrhythmias include paroxysmal supraventricular tachy- Atrial fibrillation cardia, atrial flutter, atrial fibrillation, and Atrial flutter atrial tachycardia.2,3 Atrial fibrillation is the Atrial tachycardia most common tachydysrhythmia in these pa- Paroxysmal supraventricular tachycardia tients.12 Rarely, a ventricular escape tachy- Ventricular (escape) tachyarrhythmia arrhythmia may be seen on ECG.8 Sinus node Alternating bradycardias and tachycardias re-entrant rhythm is another ECG manifesta- Bradycardia-tachycardia syndrome tion.5 Bradycardia-tachycardia syndrome may be seen on ECG or cardiac rhythm strip Adapted with permission from Wahls SA. Sick sinus (Figure 1); this syndrome is more common in syndrome. Am Fam Physician 1985;31:120. older patients with advanced sick sinus syndrome.3 FIGURE 1. Electrocardiogram exhibiting alternating patterns of bradycardia and tachycardia as seen in patients with sick sinus syndrome. APRIL 15, 2003 / VOLUME 67, NUMBER 8 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1727 TABLE 4 Indications for Permanent Pacemaker Implantation in Sick Sinus Syndrome Class I* 1. SSS with documented symptomatic bradycardia, including frequent sinus pauses that produce symptoms. In some patients, bradycardia is iatrogenic and will occur as a consequence of essential long-term drug therapy of a type and dosage for which there are no acceptable alternatives. with ECG changes.2 If the patient is asympto- 2. Symptomatic chronotropic incompetence matic when ECG or ambulatory monitoring is Class IIa performed, the dysrhythmias of the syndrome 1. SSS occurring spontaneously
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