Sinus Node Dysfunction Treatment & Management

  • Author: Yingbo Yang, MD, PhD; Chief Editor: Jeffrey N Rottman, MD   more...
 
Updated: Apr 6, 2011
 

Medical Care

The only effective medical care in patients with SND is to correct extrinsic causes.

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Surgical Care

Pacemaker therapy is the only effective surgical care for patients with chronic symptomatic SND.

Because the incidence of sudden death in patients with SND is extremely low and pacemaker therapy does not appear to affect survival, the major goal of pacemaker therapy in patients with SND is to relieve symptoms.

Pacemaker indications

According to the 2008 American College of Cardiology guidelines, pacemaker therapy has the following:[2]

  • Class I indication for patients with documented symptomatic sinus bradycardia, sinus pause, and chronotropic incompetence. This includes patients who have iatrogenic SND secondary to essential medications for which no acceptable alternatives exist.
  • Class IIa indication for patients with SND and a sinus rate < 40 bpm when a clear association between symptoms (ie, symptoms consistent with bradycardia) and bradycardia has not been documented.
  • Class IIa indication for patients with syncope of unexplained origin when clinically significant abnormalities of sinus node are discovered or provoked in electrophysiological studies.
  • Class IIb indication for patients with minimal symptoms and chronic heart rate less than 40 bpm while awake.

Pacemaker therapy is contraindicated (class III indication) for patients with asymptomatic SND or symptomatic bradycardia due to medications that are not essential.

Pacemaker selection

  • Single- versus dual-chamber pacemaker
    • In patients with SND, the annual incidence of complete heart block is about 0.6%.[23]
    • In the United States, a dual-chamber pacemaker is preferred in practice because it anticipates the possible subsequent development of conducting system dysfunction. This practice is supported by a recently published DANPACE trial where 9.3% of patients with single atrial lead (AAIR) required upgrade to dual-chamber pacemaker (DDDR) over 5.4 years follow-up due to new development of significant AV conduction abnormalities, even though these patients have no significant intraventricular conduction abnormality, PR intervals of < 260 ms, and no Wenckebach AV block with atrial pacing at 100 bpm at baseline. In addition, patients in AAIR mode had more atrial fibrillation than patients in DDDR mode with an adjusted hazard ratio of 1.24 (1.01-1.52) using their specific AV delay algorithm. Importantly, no significant mortality difference between AAIR and DDDR mode was noted.[24]
    • Arguably, a single-chamber atrial pacemaker with AAI mode is an acceptable alternative in patients with SND and normal AV and intraventricular conduction because of added expense and potential more lead extraction in patients with dual-chamber pacemaker.
    • In patients with SND and known AV conduction abnormality (including bundle branch block and bifascicular block), dual-chamber pacemaker should be used due to the high risk of AV block (about 36% in a 5-year follow-up study).[25]
  • Pacemaker programming features
    • Chronic right ventricular pacing has been shown to be associated with an increased incidence of atrial fibrillation, stroke, heart failure, and probably death.[26, 27, 28] A recent study suggested that RV pacing is detrimental to LV function even in patients with normal LVEF.[29] Therefore, avoiding right ventricular pacing is advantageous in patients with SND treated with pacemaker therapy.
    • However, using the intrinsic AV conduction in patients with a very long intrinsic PR interval may not be beneficial clinically as suggested by a recent trial in ICD patients.[24] Theoretically, a very long PR interval may result in pacemaker syndrome during sinus tachycardia or fast atrial pacing rhythm. In the DANPACE trial, about 65% of patients with a moderate AV delay setting in DDDR mode with mean RV pacing have less atrial fibrillation and no increased rate of heart failure as compared with patients in AAIR mode. Clearly, the optimal AV delay settings in patients with SND are still unknown, though various programming algorithms from different pacemaker companies are very effective in reducing right ventricular pacing.
  • Mode switch is an important feature to monitor atrial flutter and fibrillation events. Because over time more than 50% of patients with SND may develop tachy-brady syndrome[8] , it is very important to identify these patients through pacemaker monitoring and anticoagulate them to reduce their risk of stroke. However, the most appropriate anticoagulant therapy is still uncertain for patients in whom atrial fibrillation is only detected as an incidental finding on pacemaker or ICD diagnostics.
  • Pacemakers with a rate drop response program may benefit some patients with neurocardiogenic syncope. Recent studies suggesting close-loop stimulation technique in the Biotronic pacemaker may be quite helpful in reducing syncope in patients with neurocardiogenic syncope.[30, 31]
  • Rate response features have been used in patients with SND especially in the presence of chronotropic incompetence. The clinical benefits of this program feature are still controversial.[32]
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Consultations

Cardiac electrophysiology consult

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Diet

No specific dietary recommendations exist.

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Activity

Patients with symptomatic SND and not on pacemaker therapy should titrate their level of activity to minimize symptoms.

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Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Yingbo Yang, MD, PhD  Clinical Assistant Professor of Cardiovascular Medicine, Division of Cardiology, Lawrence J Ellison Ambulatory Care Center, University of California, Davis, Medical Center

Yingbo Yang, MD, PhD is a member of the following medical societies: American College of Cardiology and Heart Rhythm Society

Disclosure: Nothing to disclose.

Coauthor(s)

Yasir Batres, MD  Fellow, Division of Cardiology, University of California, Davis, Medical Center

Yasir Batres, MD is a member of the following medical societies: American College of Cardiology

Disclosure: Nothing to disclose.

Specialty Editor Board

Justin D Pearlman, MD, PhD, ME, MA  Director of Advanced Cardiovascular Imaging, Professor of Medicine, Professor of Radiology, Adjunct Professor, Thayer Bioengineering and Computer Science, Dartmouth-Hitchcock Medical Center

Justin D Pearlman, MD, PhD, ME, MA is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Federation for Medical Research, International Society for Magnetic Resonance in Medicine, and Radiological Society of North America

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Brian Olshansky, MD  Professor of Medicine, Department of Internal Medicine, University of Iowa College of Medicine

Brian Olshansky, MD is a member of the following medical societies: American Autonomic Society, American College of Cardiology, American College of Chest Physicians, American College of Physicians, American College of Sports Medicine, American Federation for Clinical Research, American Heart Association, Cardiac Electrophysiology Society, Heart Rhythm Society, and New York Academy of Sciences

Disclosure: Guidant/Boston Scientific Honoraria Speaking and teaching; Medtronic Honoraria Speaking and teaching; Guidant/Boston Scientific Consulting fee Consulting; Novartis Honoraria Speaking and teaching; Novartis Consulting fee Consulting

Amer Suleman, MD  Private Practice

Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Chief Editor

Jeffrey N Rottman, MD  Professor of Medicine and Pharmacology, Vanderbilt University School of Medicine; Chief, Department of Cardiology, Nashville Veterans Affairs Medical Center

Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association and North American Society of Pacing and Electrophysiology (NASPE)

Disclosure: Nothing to disclose.

Acknowledgments

We thank Dr. Adrian W Messerli, MD and professor Alan D Forker, MD for their important contributions to this article as the authors of its previous edition.

References

  1. Ferrer MI. The sick sinus syndrome in atrial disease. JAMA. Oct 14 1968;206(3):645-6. [Medline].

  2. [Guideline] Epstein AE, DiMarco JP, Ellenbogen KA, Estes NA 3rd, Freedman RA, Gettes LS, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol. May 27 2008;51(21):e1-62. [Medline].

  3. Dobrzynski H, Boyett MR, Anderson RH. New insights into pacemaker activity: promoting understanding of sick sinus syndrome. Circulation. Apr 10 2007;115(14):1921-32. [Medline].

  4. Rodriguez RD, Schocken DD. Update on sick sinus syndrome, a cardiac disorder of aging. Geriatrics. Jan 1990;45(1):26-30, 33-6. [Medline].

  5. Menozzi C, Brignole M, Alboni P, Boni L, Paparella N, Gaggioli G, et al. The natural course of untreated sick sinus syndrome and identification of the variables predictive of unfavorable outcome. Am J Cardiol. Nov 15 1998;82(10):1205-9. [Medline].

  6. Simon AB, Janz N. Symptomatic bradyarrhythmias in the adult: natural history following ventricular pacemaker implantation. Pacing Clin Electrophysiol. May 1982;5(3):372-83. [Medline].

  7. Alt E, Völker R, Wirtzfeld A, Ulm K. Survival and follow-up after pacemaker implantation: a comparison of patients with sick sinus syndrome, complete heart block, and atrial fibrillation. Pacing Clin Electrophysiol. Nov 1985;8(6):849-55. [Medline].

  8. Lamas GA, Lee KL, Sweeney MO, Silverman R, Leon A, Yee R, et al. Ventricular pacing or dual-chamber pacing for sinus-node dysfunction. N Engl J Med. Jun 13 2002;346(24):1854-62. [Medline].

  9. Adán V, Crown LA. Diagnosis and treatment of sick sinus syndrome. Am Fam Physician. Apr 15 2003;67(8):1725-32. [Medline].

  10. Chen PS, Joung B, Shinohara T, Das M, Chen Z, Lin SF. The initiation of the heart beat. Circ J. Feb 2010;74(2):221-5. [Medline].

  11. Jones SA, Boyett MR, Lancaster MK. Declining into failure: the age-dependent loss of the L-type calcium channel within the sinoatrial node. Circulation. Mar 13 2007;115(10):1183-90. [Medline].

  12. Hocini M, Sanders P, Deisenhofer I, Jaïs P, Hsu LF, Scavée C, et al. Reverse remodeling of sinus node function after catheter ablation of atrial fibrillation in patients with prolonged sinus pauses. Circulation. Sep 9 2003;108(10):1172-5. [Medline].

  13. Yeh YH, Burstein B, Qi XY, Sakabe M, Chartier D, Comtois P, et al. Funny current downregulation and sinus node dysfunction associated with atrial tachyarrhythmia: a molecular basis for tachycardia-bradycardia syndrome. Circulation. Mar 31 2009;119(12):1576-85. [Medline].

  14. Joung B, Lin SF, Chen Z, Antoun PS, Maruyama M, Han S. Mechanisms of sinoatrial node dysfunction in a canine model of pacing-induced atrial fibrillation. Heart Rhythm. Jan 2010;7(1):88-95. [Medline].

  15. Stein R, Medeiros CM, Rosito GA, Zimerman LI, Ribeiro JP. Intrinsic sinus and atrioventricular node electrophysiologic adaptations in endurance athletes. J Am Coll Cardiol. Mar 20 2002;39(6):1033-8. [Medline].

  16. Spodick DH. Normal sinus heart rate: sinus tachycardia and sinus bradycardia redefined. Am Heart J. Oct 1992;124(4):1119-21. [Medline].

  17. Hilgard J, Ezri MD, Denes P. Significance of ventricular pauses of three seconds or more detected on twenty-four-hour Holter recordings. Am J Cardiol. Apr 1 1985;55(8):1005-8. [Medline].

  18. Katritsis D, Camm AJ. Chronotropic incompetence: a proposal for definition and diagnosis. Br Heart J. Nov 1993;70(5):400-2. [Medline].

  19. Jose AD, Collison D. The normal range and determinants of the intrinsic heart rate in man. Cardiovasc Res. Apr 1970;4(2):160-7. [Medline].

  20. Jordan JL, Yamaguchi I, Mandel WJ. Studies on the mechanism of sinus node dysfunction in the sick sinus syndrome. Circulation. Feb 1978;57(2):217-23. [Medline].

  21. Josephson ME. Clinical Cardiac Electrophysiology. 3rd. 2002.

  22. Alboni P, Menozzi C, Brignole M, Paparella N, Gaggioli G, Lolli G, et al. Effects of permanent pacemaker and oral theophylline in sick sinus syndrome the THEOPACE study: a randomized controlled trial. Circulation. Jul 1 1997;96(1):260-6. [Medline].

  23. Rosenqvist M, Obel IW. Atrial pacing and the risk for AV block: is there a time for change in attitude?. Pacing Clin Electrophysiol. Jan 1989;12(1 Pt 1):97-101. [Medline].

  24. Nielsen JC, Thomsen PE, Hojberg S, Moller M, Vesterlund T, Dalsgaard D, et al. A comparison of single-lead atrial pacing with dual-chamber pacing in sick sinus syndrome. Eur Heart J. Mar 2011;32(6):686-696. [Medline].

  25. Brandt J, Anderson H, Fåhraeus T, Schüller H. Natural history of sinus node disease treated with atrial pacing in 213 patients: implications for selection of stimulation mode. J Am Coll Cardiol. Sep 1992;20(3):633-9. [Medline].

  26. Andersen HR, Thuesen L, Bagger JP, Vesterlund T, Thomsen PE. Prospective randomised trial of atrial versus ventricular pacing in sick-sinus syndrome. Lancet. Dec 3 1994;344(8936):1523-8. [Medline].

  27. Lamas GA, Lee KL, Sweeney MO, Silverman R, Leon A, Yee R. Ventricular pacing or dual-chamber pacing for sinus-node dysfunction. N Engl J Med. Jun 13 2002;346(24):1854-62. [Medline].

  28. Sweeney MO, Bank AJ, Nsah E, Koullick M, Zeng QC, Hettrick D. Minimizing ventricular pacing to reduce atrial fibrillation in sinus-node disease. N Engl J Med. Sep 6 2007;357(10):1000-8. [Medline].

  29. Yu CM, Chan JY, Zhang Q, Omar R, Yip GW, Hussin A. Biventricular pacing in patients with bradycardia and normal ejection fraction. N Engl J Med. Nov 26 2009;361(22):2123-34. [Medline].

  30. Kanjwal K, Karabin B, Kanjwal Y, Grubb BP. Preliminary observations on the use of closed-loop cardiac pacing in patients with refractory neurocardiogenic syncope. J Interv Card Electrophysiol. Jan 2010;27(1):69-73. [Medline].

  31. Occhetta E, Bortnik M, Audoglio R, Vassanelli C. Closed loop stimulation in prevention of vasovagal syncope. Inotropy Controlled Pacing in Vasovagal Syncope (INVASY): a multicentre randomized, single blind, controlled study. Europace. Nov 2004;6(6):538-47. [Medline].

  32. Lamas GA, Knight JD, Sweeney MO, Mianulli M, Jorapur V, Khalighi K. Impact of rate-modulated pacing on quality of life and exercise capacity--evidence from the Advanced Elements of Pacing Randomized Controlled Trial (ADEPT). Heart Rhythm. Sep 2007;4(9):1125-32. [Medline].

 
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