Sick sinus syndrome: Treatment
- Munther K Homoud, MD
Munther K Homoud, MD
- Associate Professor of Medicine
- Tufts University School of Medicine
Sick sinus syndrome (SSS) is characterized by dysfunction of the sinoatrial (SA) node that is often secondary to senescence of the SA node and surrounding atrial myocardium. The initial clues to the diagnosis of SSS are often derived from taking the history and obtaining a routine electrocardiogram (ECG), though the symptoms (eg, fatigue, lightheadedness, palpitations, presyncope, and/or syncope) and ECG findings are frequently vague and nonspecific. The occasional patient may be identified during a standard ECG or ambulatory ECG monitoring performed for another indication. Different forms of SSS exist electrophysiologically from inappropriate sinus bradycardia, chronotropic incompetence, sinus pauses, SA exit block and the tachycardia-bradycardia syndrome. Treatment of SSS is directed at symptoms and typically involves the implantation of a permanent pacemaker. (See "Permanent cardiac pacing: Overview of devices and indications".)
The treatment of SSS will be reviewed here. The etiologies, clinical manifestations, diagnosis, evaluation, and natural history are discussed in detail separately. (See "Sick sinus syndrome: Epidemiology, etiology, and natural history" and "Sick sinus syndrome: Clinical manifestations, diagnosis, and evaluation" and "Arrhythmia management for the primary care clinician", section on 'Referral to a specialist'.)
SSS is a clinical syndrome characterized by chronic sinoatrial (SA) node dysfunction, a sluggish or absent SA nodal pacemaker after electrical cardioversion, and/or depressed escape pacemakers in the presence or absence of atrioventricular (AV) nodal conduction disturbances [1-3]. SSS may also manifest as chronotropic incompetence with inappropriate heart rate responses to physiologic demands during activity. SSS can also be accompanied by AV nodal conduction disturbances and by atrial tachyarrhythmias as part of the tachycardia-bradycardia syndrome. (See "Sick sinus syndrome: Epidemiology, etiology, and natural history", section on 'Definition of SSS'.)
Treatment of SSS is directed at ameliorating symptoms, which may include lightheadedness, presyncope, syncope, and, less often, dyspnea on exertion or worsening angina. In addition, patients with tachycardia-bradycardia syndrome may present with palpitations and other symptoms associated with a rapid heart rate. While some individuals present with frank syncope, patients more commonly report progressive development of symptoms and often equate this with natural aging. Specific treatment for the control of symptomatic SSS usually involves the implantation of a pacemaker. There is a limited role for pharmacologic intervention in symptomatic and/or hemodynamically unstable sinoatrial (SA) node dysfunction. Definitive therapy of irreversible SA node dysfunction requires the implantation of a permanent pacemaker. (See "Sick sinus syndrome: Epidemiology, etiology, and natural history" and 'Long-term management' below.)
It is important to recognize that there may be an "extrinsic" component to SSS compounding the "intrinsic" component inherent to the dysfunctional SA node. The most common of these extrinsic agents are pharmacologic agents. The higher prevalence of hypertension, coronary artery disease, and atrial fibrillation (AF) in the same group of patients with SSS would make it more likely that the pharmacologic regimen of such patients may include beta adrenergic blockers, non-dihydropyridine calcium channel blockers, and antiarrhythmic agents, all of which would potentially exacerbate any underlying SA node dysfunction.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- Initial management
- - Unstable patients
- - Stable patients
- Long-term management
- - Asymptomatic patients
- - Symptomatic patients
- Permanent pacing
- Pharmacologic therapy
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