Sick sinus syndrome medical therapy: Difference between revisions
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{{CMG}}; {{AE}} {{Sahar}} | {{CMG}}; {{AE}} {{Sahar}} | ||
==Overview== | ==Overview== | ||
The management of sick sinus syndrome depends on the underlying | The management of sick sinus syndrome depends on the underlying cause and the presenting [[symptoms]]. After correcting the reversible [[causes]] of sick sinus syndrome, it can be managed by placing an implantable [[pacemaker]]. [[Asymptomatic]] [[patients]] are usually monitored without therapy. [[Atropine]] may be used in the presence of [[symptoms]] or [[hemodynamic compromise]]. | ||
==Medical Therapy== | ==Medical Therapy== | ||
The management of sick sinus syndrome depends on the underlying [[cause]] and the presenting [[symptoms]]. After correcting the reversible [[causes]] of sick sinus syndrome, it can be managed by placing an implantable pacemaker.<ref name="pmid29261930">{{cite journal |vauthors=Dakkak W, Doukky R |title= |journal= |volume= |issue= |pages= |date= |pmid=29261930 |doi= |url=}}</ref> | The management of sick sinus syndrome depends on the underlying [[cause]] and the presenting [[symptoms]]. After correcting the reversible [[causes]] of sick sinus syndrome, it can be managed by placing an implantable [[pacemaker]].<ref name="pmid29261930">{{cite journal |vauthors=Dakkak W, Doukky R |title= |journal= |volume= |issue= |pages= |date= |pmid=29261930 |doi= |url=}}</ref> | ||
*Clinical [[indications]] of the implantable pacemaker include: | *Clinical [[Indications and usage|indications]] of the implantable [[pacemaker]] include: | ||
** [[Patients]] with documented bradycardia and are symptomatic | **[[Patients]] with documented bradycardia and are [[symptomatic]] | ||
** [[Patients]] with chronotropic incompetence | **[[Patients]] with chronotropic incompetence | ||
** Sinus node dysfunction secondary to medications necessitated by another medical condition | ** Sinus node dysfunction secondary to medications necessitated by another [[medical condition]] | ||
** [[Patients]] with heart rate < 40 per minute | **[[Patients]] with [[heart rate]] < 40 per minute | ||
*Asymptomatic patients are followed without any treatment. | *[[Asymptomatic]] [[patients]] are followed without any treatment. | ||
*Pharmacologic agents for the treatment of sick siuns syndrome include: | *Pharmacologic agents for the treatment of sick siuns syndrome include: | ||
**Caffeine | **[[Caffeine]] | ||
**β-sympathomimetics (e.g., theophylline) | **β-sympathomimetics (e.g., [[theophylline]]) | ||
**Oral vagolytic agents such as glycopyrrolate or atropine | **Oral vagolytic agents such as [[glycopyrrolate]] or [[atropine]] | ||
*Asymptomatic patients are usually monitored without therapy. | *[[Asymptomatic]] [[patients]] are usually monitored without therapy. | ||
*[[Atropine]] may be used in the presence of [[symptoms]] or [[hemodynamic compromise]]. | |||
== 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay <ref name="KusumotoSchoenfeld2019">{{cite journal|last1=Kusumoto|first1=Fred M.|last2=Schoenfeld|first2=Mark H.|last3=Barrett|first3=Coletta|last4=Edgerton|first4=James R.|last5=Ellenbogen|first5=Kenneth A.|last6=Gold|first6=Michael R.|last7=Goldschlager|first7=Nora F.|last8=Hamilton|first8=Robert M.|last9=Joglar|first9=José A.|last10=Kim|first10=Robert J.|last11=Lee|first11=Richard|last12=Marine|first12=Joseph E.|last13=McLeod|first13=Christopher J.|last14=Oken|first14=Keith R.|last15=Patton|first15=Kristen K.|last16=Pellegrini|first16=Cara N.|last17=Selzman|first17=Kimberly A.|last18=Thompson|first18=Annemarie|last19=Varosy|first19=Paul D.|title=2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society|journal=Circulation|volume=140|issue=8|year=2019|issn=0009-7322|doi=10.1161/CIR.0000000000000627}}</ref> == | == 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay <ref name="KusumotoSchoenfeld2019">{{cite journal|last1=Kusumoto|first1=Fred M.|last2=Schoenfeld|first2=Mark H.|last3=Barrett|first3=Coletta|last4=Edgerton|first4=James R.|last5=Ellenbogen|first5=Kenneth A.|last6=Gold|first6=Michael R.|last7=Goldschlager|first7=Nora F.|last8=Hamilton|first8=Robert M.|last9=Joglar|first9=José A.|last10=Kim|first10=Robert J.|last11=Lee|first11=Richard|last12=Marine|first12=Joseph E.|last13=McLeod|first13=Christopher J.|last14=Oken|first14=Keith R.|last15=Patton|first15=Kristen K.|last16=Pellegrini|first16=Cara N.|last17=Selzman|first17=Kimberly A.|last18=Thompson|first18=Annemarie|last19=Varosy|first19=Paul D.|title=2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society|journal=Circulation|volume=140|issue=8|year=2019|issn=0009-7322|doi=10.1161/CIR.0000000000000627}}</ref> == | ||
=== Acute Management of Reversible Causes of Sinus Node Dysfunction === | === Acute Management of Reversible Causes of Sinus Node Dysfunction === | ||
| Line 23: | Line 25: | ||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In symptomatic patients presenting with sinus node dysfunction (SND), evaluation and treatment of reversible causes is recommended. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In [[symptomatic]] [[patients]] presenting with sinus node dysfunction (SND), evaluation and treatment of reversible [[causes]] is recommended. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|} | |} | ||
=== Acute Medical Therapy for Bradycardia=== | === Acute Medical Therapy for Bradycardia=== | ||
| Line 30: | Line 32: | ||
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''In patients with SND associated with symptoms or hemodynamic compromise, atropine is reasonable to increase sinus rate ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> <ref name="BradySwart1999">{{cite journal|last1=Brady|first1=William J.|last2=Swart|first2=Gary|last3=DeBehnke|first3=Daniel J.|last4=Ma|first4=O.John|last5=Aufderheide|first5=Tom P.|title=The efficacy of atropine in the treatment of hemodynamically unstable bradycardia and atrioventricular block: prehospital and emergency department considerations|journal=Resuscitation|volume=41|issue=1|year=1999|pages=47–55|issn=03009572|doi=10.1016/S0300-9572(99)00032-5}}</ref> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''In [[patients]] with SND associated with [[symptoms]] or [[hemodynamic compromise]], [[atropine]] is reasonable to increase [[sinus rate]] ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> <ref name="BradySwart1999">{{cite journal|last1=Brady|first1=William J.|last2=Swart|first2=Gary|last3=DeBehnke|first3=Daniel J.|last4=Ma|first4=O.John|last5=Aufderheide|first5=Tom P.|title=The efficacy of atropine in the treatment of hemodynamically unstable bradycardia and atrioventricular block: prehospital and emergency department considerations|journal=Resuscitation|volume=41|issue=1|year=1999|pages=47–55|issn=03009572|doi=10.1016/S0300-9572(99)00032-5}}</ref> | ||
|} | |} | ||
{|class="wikitable" | {|class="wikitable" | ||
| Line 36: | Line 38: | ||
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.'''In patients with SND associated with symptoms or hemodynamic compromise who are at low likelihood of coronary ischemia, isoproterenol, dopamine, dobutamine, or epinephrine may be considered to increase heart rate and improve symptoms.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> <ref name="GeeKarsies2015">{{cite journal|last1=Gee|first1=Samantha W.|last2=Karsies|first2=Todd J.|title=Listeria meningitis–associated bradyarrhythmia treated with isoproterenol|journal=The American Journal of Emergency Medicine|volume=33|issue=2|year=2015|pages=306.e1–306.e2|issn=07356757|doi=10.1016/j.ajem.2014.06.022}}</ref><ref name="MorrisonLong2008">{{cite journal|last1=Morrison|first1=Laurie J.|last2=Long|first2=Jennifer|last3=Vermeulen|first3=Marian|last4=Schwartz|first4=Brian|last5=Sawadsky|first5=Bruce|last6=Frank|first6=Jamie|last7=Cameron|first7=Bruce|last8=Burgess|first8=Robert|last9=Shield|first9=Jennifer|last10=Bagley|first10=Paul|last11=Mausz|first11=Vivien|last12=Brewer|first12=James E.|last13=Dorian|first13=Paul|title=A randomized controlled feasibility trial comparing safety and effectiveness of prehospital pacing versus conventional treatment: ‘PrePACE’|journal=Resuscitation|volume=76|issue=3|year=2008|pages=341–349|issn=03009572|doi=10.1016/j.resuscitation.2007.08.008}}</ref> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.'''In [[patients]] with SND associated with [[symptoms]] or [[hemodynamic compromise]] who are at low likelihood of [[coronary ischemia]], [[isoproterenol]], [[dopamine]], [[dobutamine]], or [[epinephrine]] may be considered to increase [[heart rate]] and improve [[symptoms]].''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> <ref name="GeeKarsies2015">{{cite journal|last1=Gee|first1=Samantha W.|last2=Karsies|first2=Todd J.|title=Listeria meningitis–associated bradyarrhythmia treated with isoproterenol|journal=The American Journal of Emergency Medicine|volume=33|issue=2|year=2015|pages=306.e1–306.e2|issn=07356757|doi=10.1016/j.ajem.2014.06.022}}</ref><ref name="MorrisonLong2008">{{cite journal|last1=Morrison|first1=Laurie J.|last2=Long|first2=Jennifer|last3=Vermeulen|first3=Marian|last4=Schwartz|first4=Brian|last5=Sawadsky|first5=Bruce|last6=Frank|first6=Jamie|last7=Cameron|first7=Bruce|last8=Burgess|first8=Robert|last9=Shield|first9=Jennifer|last10=Bagley|first10=Paul|last11=Mausz|first11=Vivien|last12=Brewer|first12=James E.|last13=Dorian|first13=Paul|title=A randomized controlled feasibility trial comparing safety and effectiveness of prehospital pacing versus conventional treatment: ‘PrePACE’|journal=Resuscitation|volume=76|issue=3|year=2008|pages=341–349|issn=03009572|doi=10.1016/j.resuscitation.2007.08.008}}</ref> | ||
|} | |} | ||
{|class="wikitable" | {|class="wikitable" | ||
| Line 42: | Line 44: | ||
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit) | | colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit) | ||
|- | |- | ||
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''3.''' In patients who have undergone heart transplant without evidence for autonomic reinnervation, atropine should not be used to treat sinus bradycardia. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki><ref name="BernheimFatio2004">{{cite journal|last1=Bernheim|first1=Alain|last2=Fatio|first2=Renate|last3=Kiowski|first3=Wolfgang|last4=Weilenmann|first4=Daniel|last5=Rickli|first5=Hans|last6=Rocca|first6=Hans Peter Brunner-La|title=ATROPINE OFTEN RESULTS IN COMPLETE ATRIOVENTRICULAR BLOCK OR SINUS ARREST AFTER CARDIAC TRANSPLANTATION: AN UNPREDICTABLE AND DOSE-INDEPENDENT PHENOMENON|journal=Transplantation|volume=77|issue=8|year=2004|pages=1181–1185|issn=0041-1337|doi=10.1097/01.TP.0000122416.70287.D9}}</ref><ref name="LinkBerkow2015">{{cite journal|last1=Link|first1=Mark S.|last2=Berkow|first2=Lauren C.|last3=Kudenchuk|first3=Peter J.|last4=Halperin|first4=Henry R.|last5=Hess|first5=Erik P.|last6=Moitra|first6=Vivek K.|last7=Neumar|first7=Robert W.|last8=O’Neil|first8=Brian J.|last9=Paxton|first9=James H.|last10=Silvers|first10=Scott M.|last11=White|first11=Roger D.|last12=Yannopoulos|first12=Demetris|last13=Donnino|first13=Michael W.|title=Part 7: Adult Advanced Cardiovascular Life Support|journal=Circulation|volume=132|issue=18 suppl 2|year=2015|pages=S444–S464|issn=0009-7322|doi=10.1161/CIR.0000000000000261}}</ref> | | bgcolor="LightCoral"|<nowiki>"</nowiki>'''3.''' In [[Patient|patients]] who have undergone [[heart transplant]] without evidence for autonomic reinnervation, [[atropine]] should not be used to treat [[sinus bradycardia]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki><ref name="BernheimFatio2004">{{cite journal|last1=Bernheim|first1=Alain|last2=Fatio|first2=Renate|last3=Kiowski|first3=Wolfgang|last4=Weilenmann|first4=Daniel|last5=Rickli|first5=Hans|last6=Rocca|first6=Hans Peter Brunner-La|title=ATROPINE OFTEN RESULTS IN COMPLETE ATRIOVENTRICULAR BLOCK OR SINUS ARREST AFTER CARDIAC TRANSPLANTATION: AN UNPREDICTABLE AND DOSE-INDEPENDENT PHENOMENON|journal=Transplantation|volume=77|issue=8|year=2004|pages=1181–1185|issn=0041-1337|doi=10.1097/01.TP.0000122416.70287.D9}}</ref><ref name="LinkBerkow2015">{{cite journal|last1=Link|first1=Mark S.|last2=Berkow|first2=Lauren C.|last3=Kudenchuk|first3=Peter J.|last4=Halperin|first4=Henry R.|last5=Hess|first5=Erik P.|last6=Moitra|first6=Vivek K.|last7=Neumar|first7=Robert W.|last8=O’Neil|first8=Brian J.|last9=Paxton|first9=James H.|last10=Silvers|first10=Scott M.|last11=White|first11=Roger D.|last12=Yannopoulos|first12=Demetris|last13=Donnino|first13=Michael W.|title=Part 7: Adult Advanced Cardiovascular Life Support|journal=Circulation|volume=132|issue=18 suppl 2|year=2015|pages=S444–S464|issn=0009-7322|doi=10.1161/CIR.0000000000000261}}</ref> | ||
|} | |} | ||
==References== | ==References== | ||
Latest revision as of 01:34, 9 April 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2]
Overview
The management of sick sinus syndrome depends on the underlying cause and the presenting symptoms. After correcting the reversible causes of sick sinus syndrome, it can be managed by placing an implantable pacemaker. Asymptomatic patients are usually monitored without therapy. Atropine may be used in the presence of symptoms or hemodynamic compromise.
Medical Therapy
The management of sick sinus syndrome depends on the underlying cause and the presenting symptoms. After correcting the reversible causes of sick sinus syndrome, it can be managed by placing an implantable pacemaker.[1]
- Clinical indications of the implantable pacemaker include:
- Patients with documented bradycardia and are symptomatic
- Patients with chronotropic incompetence
- Sinus node dysfunction secondary to medications necessitated by another medical condition
- Patients with heart rate < 40 per minute
- Asymptomatic patients are followed without any treatment.
- Pharmacologic agents for the treatment of sick siuns syndrome include:
- Caffeine
- β-sympathomimetics (e.g., theophylline)
- Oral vagolytic agents such as glycopyrrolate or atropine
- Asymptomatic patients are usually monitored without therapy.
- Atropine may be used in the presence of symptoms or hemodynamic compromise.
2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay [2]
Acute Management of Reversible Causes of Sinus Node Dysfunction
| Class I |
| "1. In symptomatic patients presenting with sinus node dysfunction (SND), evaluation and treatment of reversible causes is recommended. (Level of Evidence: C)" |
Acute Medical Therapy for Bradycardia
| Class IIa |
| "1.In patients with SND associated with symptoms or hemodynamic compromise, atropine is reasonable to increase sinus rate (Level of Evidence: C)" [3] |
| Class IIb |
| "2.In patients with SND associated with symptoms or hemodynamic compromise who are at low likelihood of coronary ischemia, isoproterenol, dopamine, dobutamine, or epinephrine may be considered to increase heart rate and improve symptoms.(Level of Evidence: C)" [4][5] |
| Class III (No Benefit) |
| "3. In patients who have undergone heart transplant without evidence for autonomic reinnervation, atropine should not be used to treat sinus bradycardia. (Level of Evidence: C)"[6][7] |
References
- ↑ Dakkak W, Doukky R. PMID 29261930. Missing or empty
|title=(help) - ↑ Kusumoto, Fred M.; Schoenfeld, Mark H.; Barrett, Coletta; Edgerton, James R.; Ellenbogen, Kenneth A.; Gold, Michael R.; Goldschlager, Nora F.; Hamilton, Robert M.; Joglar, José A.; Kim, Robert J.; Lee, Richard; Marine, Joseph E.; McLeod, Christopher J.; Oken, Keith R.; Patton, Kristen K.; Pellegrini, Cara N.; Selzman, Kimberly A.; Thompson, Annemarie; Varosy, Paul D. (2019). "2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society". Circulation. 140 (8). doi:10.1161/CIR.0000000000000627. ISSN 0009-7322.
- ↑ Brady, William J.; Swart, Gary; DeBehnke, Daniel J.; Ma, O.John; Aufderheide, Tom P. (1999). "The efficacy of atropine in the treatment of hemodynamically unstable bradycardia and atrioventricular block: prehospital and emergency department considerations". Resuscitation. 41 (1): 47–55. doi:10.1016/S0300-9572(99)00032-5. ISSN 0300-9572.
- ↑ Gee, Samantha W.; Karsies, Todd J. (2015). "Listeria meningitis–associated bradyarrhythmia treated with isoproterenol". The American Journal of Emergency Medicine. 33 (2): 306.e1–306.e2. doi:10.1016/j.ajem.2014.06.022. ISSN 0735-6757.
- ↑ Morrison, Laurie J.; Long, Jennifer; Vermeulen, Marian; Schwartz, Brian; Sawadsky, Bruce; Frank, Jamie; Cameron, Bruce; Burgess, Robert; Shield, Jennifer; Bagley, Paul; Mausz, Vivien; Brewer, James E.; Dorian, Paul (2008). "A randomized controlled feasibility trial comparing safety and effectiveness of prehospital pacing versus conventional treatment: 'PrePACE'". Resuscitation. 76 (3): 341–349. doi:10.1016/j.resuscitation.2007.08.008. ISSN 0300-9572.
- ↑ Bernheim, Alain; Fatio, Renate; Kiowski, Wolfgang; Weilenmann, Daniel; Rickli, Hans; Rocca, Hans Peter Brunner-La (2004). "ATROPINE OFTEN RESULTS IN COMPLETE ATRIOVENTRICULAR BLOCK OR SINUS ARREST AFTER CARDIAC TRANSPLANTATION: AN UNPREDICTABLE AND DOSE-INDEPENDENT PHENOMENON". Transplantation. 77 (8): 1181–1185. doi:10.1097/01.TP.0000122416.70287.D9. ISSN 0041-1337.
- ↑ Link, Mark S.; Berkow, Lauren C.; Kudenchuk, Peter J.; Halperin, Henry R.; Hess, Erik P.; Moitra, Vivek K.; Neumar, Robert W.; O’Neil, Brian J.; Paxton, James H.; Silvers, Scott M.; White, Roger D.; Yannopoulos, Demetris; Donnino, Michael W. (2015). "Part 7: Adult Advanced Cardiovascular Life Support". Circulation. 132 (18 suppl 2): S444–S464. doi:10.1161/CIR.0000000000000261. ISSN 0009-7322.