eMedicine Specialties > Cardiology > Arrhythmias

Sinus Node Dysfunction: Treatment & Medication

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
Coauthor(s): Yasir Batres, MD, Fellow, Division of Cardiology, University of California, Davis, Medical Center
Contributor Information and Disclosures

Updated: Aug 31, 2009

Treatment

Medical Care

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

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 American College of Cardiology guidelines in 20082 , pacemaker therapy has the following:

  • 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 %.20 In the United States, a dual-chamber pacemaker is preferred in practice because it anticipates the possible subsequent development of conducting system dysfunction. A single-chamber atrial pacemaker with AAI mode, however, is acceptable therapy in patients with SND and normal AV conduction/intraventricular conduction as the overall incidence of complete heart block in very low. 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).21
  • Pacemaker programming features: AAI and dual chamber pacing are better than VVI pacing mode.22,23 If a dual chamber pacemaker is used, it is very important to use various programming algorithms to promote intrinsic AV conduction, thus reducing right ventricular pacing. Chronic right ventricular pacing has been shown to be associated with an increased incidence of atrial fibrillation, stroke, heart failure, and probably death.22,23,24
  • 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 syndrome8 , it is very important to identify these patients through pacemaker monitoring and anticoagulate them to reduce their risk of stroke.
  • Pacemakers with a "rate drop" response program may benefit some patients with neurocardiogenic syncope. Rate response to activity program is generally used in patients with SND and chronotropic incompetence. The clinical benefits of this program are still controversial.25

Consultations

Cardiac electrophysiology consult.

Diet

No specific dietary recommendations exist.

Activity

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

Medication

Currently no medications are routinely used to treat symptomatic SND.

More on Sinus Node Dysfunction

Overview: Sinus Node Dysfunction
Differential Diagnoses & Workup: Sinus Node Dysfunction
Treatment & Medication: Sinus Node Dysfunction
Follow-up: Sinus Node Dysfunction
References
[ CLOSE WINDOW ]

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. 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].

  11. 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].

  12. 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].

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

  14. 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].

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

  16. 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].

  17. 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].

  18. Josephson, ME. Clinical Cardiac Electrophysiology. 3rd edition. 2002.

  19. 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].

  20. 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].

  21. 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].

  22. 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].

  23. 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].

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

  25. Lamas GA, Knight JD, Sweeney MO, Mianulli M, Jorapur V, Khalighi K, et al. 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].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

sick sinus syndrome, sinus node dysfunction, SND, sinoatrial disease, sinoatrial dysfunction, sluggish sinus syndrome, sinus nodal dysfunction, Valsalva maneuver, carotid sinus massage, idiopathic degenerative disease, coronary artery disease, autonomic hyperactivity, intrinsic sinus nodal dysfunction, infiltrative diseases, cardiomyopathy, hypertension, collagen vascular diseases, congenital heart disease, heart transplant, musculoskeletal disorders, myocarditis, pericarditis, beta-blockers, nondihydropyridine calcium channel blockers, cardiac glycosides, sympatholytic antihypertensives, membrane-active antiarrhythmics, autonomic dysfunction, vasovagal syncope, carotid sinus syndrome, extrinsic sinus nodal dysfunction, electrolyte imbalance, hypothyroidism, hyperthyroidism, hypothermia, sepsis

[ CLOSE WINDOW ]

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.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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; Reliant Grant/research funds Other; Novartis Honoraria Speaking and teaching; Novartis Consulting fee Consulting

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
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

Michael E Zevitz, MD, Assistant Professor of Medicine, Finch University of the Health Sciences, The Chicago Medical School; Consulting Staff, Private Practice
Michael E Zevitz, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Medical Association, and Michigan State Medical Society
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.