History

Fact Explanation
Common in the elderly age group but may rarely maybe congenital Sick sinus syndrome (SSS) is characterized by sinus node dysfunction with an atrial rate which is inappropriate for physiologic requirements. This condition is most common in the elderly but can occur in persons of all ages, including neonates. The mean age of patients with SSS is 68 years, and males and females are affected equally. sinus node malfunctions can result in several different abnormalities and they are inappropriate bradycardia, inappropriate tachycardia, Tachy- Brady syndrome and sinus pause or sinus arrest. Most cases of sick sinus syndrome are idiopathic, and the cause can be related to multiple factors. Age related degenerative fibrosis of nodal tissue is the most common cause of intrinsic changes in the sinoatrial node that lead to sick sinus syndrome. There are other certain conditions can cause these intrinsic changes as well such as in heart failure and atrial fibrillation where remodeling of the sinoatrial node occurs. Also certain infiltrative disease processes, including connective tissue diseases, hemochromatosis, sarcoidosis, and amyloidosis, may also cause intrinsic dysfunction of the sinoatrial node. Atherosclerotic changes of the sinus node artery, which originates from the proximal right coronary artery may contribute to chronic ischemia and subsequent fibrosis of the sinoatrial node is regarded as a minor cause. There also are extrinsic causes of sinus node dysfunction and conditions that can cause this problem in children. Extrinsic factors are pharmacologic agents such as beta blockers, calcium channel blockers, digoxin, sympatholytic medications, antiarrhythmic medications, and lithium, metabolic disturbances such as hyperkalemia, hypokalemia, and hypocalcemia, and autonomic dysfunction. There's a congenital SSS as well due to recessive SCN5A mutations[1] [2]
Asymptomatic [1] Many people with early or mild SSS have no symptoms and apparently healthy [1]
Palpitations [1] Due to abnormal sensation of the heart beat which occurs during spells of tachycardia, bradycardia and tachy-brady syndrome [1]
syncope, pre-syncope, or light-headedness [1] [3] [4] [5] Due to inability of the heart to pump sufficient blood to the brain and resultant cerebral hypoperfusion, because of a too slow or too fast heart rate. This occurs in 50% of people and this is a form of neuro-cardiogenic syncope. [1] [3] [5]
fatigue and Weakness [1] Due to inadequate blood supply from the heart to meet the physiological needs of the body. [1]
Confusion and dementia [1] Due to insufficient blood supply to the brain due to extreme tachycardia or bradycardia [1]
Angina [1] This symptom develops when there's inadequate blood supply to the heart due to blocked arteries or because of erratic heart beat as in SSS. [1]
Disturbed sleep [1] The erratic heart rhythm may interfere with sleep which makes people wake up at night. [1]
Hemipariesis, Aphasia and Cerebrovascular accident like manifestations [4] Due to thrombo-embolism phenomena resulting from arrhythmia especially in the presence of bradycardia- tachycardia syndrome (alternating brady- arrhythmias and tachyarrhythmias), which may be related to dysrhythmia-induced emboli [4]
ankle swelling, and other features suggestive of congestive cardiac failure [4] Due to persistent arrhythmia, and angina, ultimately congestive cardiac failure may develop due to increased workload by the heart. [4]
Flushing of the face [4] Due to associated tachycardia there can be flushing of face [4]
Retrosternal pressure [4] Due to pounding of the heart associated with tachycardia, tachy-brady syndrome [4]
References
  1. GREGORATOS G.. Sick Sinus Syndrome. Circulation [online] 2003 November, 108(20):143e-144 [viewed 22 June 2014] Available from: doi:10.1161/​01.CIR.0000102938.55119.EC
  2. BENSON D. WOODROW, WANG DAO W., DYMENT MACAIRA, KNILANS TIMOTHY K., FISH FRANK A., STRIEPER MARGARET J., RHODES THOMAS H., GEORGE ALFRED L.. Congenital sick sinus syndrome caused by recessive mutations in the cardiac sodium channel gene (SCN5A). J. Clin. Invest. [online] 2003 October, 112(7):1019-1028 [viewed 22 June 2014] Available from: doi:10.1172/JCI18062
  3. ARTHUR W. The pathophysiology of common causes of syncope. [online] 2000 December, 76(902):750-753 [viewed 22 June 2014] Available from: doi:10.1136/pmj.76.902.750
  4. RUBENSTEIN J. J., SCHULMAN C. L., YURCHAK P. M., DESANCTIS R. W.. Clinical Spectrum of the Sick Sinus Syndrome. Circulation [online] 1972 July, 46(1):5-13 [viewed 22 June 2014] Available from: doi:10.1161/​01.CIR.46.1.5
  5. ALBONI P., GIANFRANCHI L., BRIGNOLE M.. Treatment of persistent sinus bradycardia with intermittent symptoms: are guidelines clear?. Europace [online] December, 11(5):562-564 [viewed 22 June 2014] Available from: doi:10.1093/europace/eup014

Examination

Fact Explanation
Flushing of the face [1] Due to associated tachycardia [1]
Tachycardia, Bradycardia or spells of Tachy-Bradycardia, long pauses without a heart beat [1] [2] There's tachycardia, Bradycardi, Tachy-Brady syndrome, sinus arrest in the clinical spectrum of the disease [1] [2]
Aphasia, Hemipareisis and cerebrovascular accident like manifestations [1] [2] [3] Due to thrombo-embolism phenomena resulting from arrhythmia especially in the presence of bradycardia- tachycardia syndrome (alternating brady- arrhythmias and tachyarrhythmias), which may be related to dysrhythmia-induced emboli [3] [1]
Confusion [1] [2] [3] Due to insufficient blood supply to the brain due to extreme tachycardia or bradycardia [1]
Signs of congestive cardiac failure such as ankle swelling, elevated jugular venous pulse, hepatomgealy [1] [3] Due to persistent arrhythmia, and angina, ultimately congestive cardiac failure may develop due to increased workload by the heart.[1] [3]
References
  1. RUBENSTEIN J. J., SCHULMAN C. L., YURCHAK P. M., DESANCTIS R. W.. Clinical Spectrum of the Sick Sinus Syndrome. Circulation [online] 1972 July, 46(1):5-13 [viewed 22 June 2014] Available from: doi:10.1161/​01.CIR.46.1.5
  2. GREGORATOS G.. Sick Sinus Syndrome. Circulation [online] 2003 November, 108(20):143e-144 [viewed 22 June 2014] Available from: doi:10.1161/​01.CIR.0000102938.55119.EC
  3. GREGORATOS G.. Sick Sinus Syndrome. Circulation [online] 2003 November, 108(20):143e-144 [viewed 22 June 2014] Available from: doi:10.1161/​01.CIR.0000102938.55119.EC

Differential Diagnoses

Fact Explanation
Vaso-vagal syncope [1] [2] Syncope is defined as a short period of self-limited loss of consciousness due to transient diminution of blood flow to the brain. The main pathophysiology of vasovagal syncope is thought to be due to autonomic cardioinhibitory and/or vasodilator response. [1] [2]
Atrial Fibrillation [3] This is the most common sustained cardiac arrhythmia, and there's increased rates of heart failure, stroke, and death in the patients with atrial fibrillation. Atrial fibrillation can occur commonly as a arrhythmia in SSS. [3]
Atrial Flutter [4] This is a cardiac dysrhythmia characterized by rapid and regular depolarization of the atria that demonstrates a sawtooth pattern on the electrocardiogram and palpitations, light-headedness, fatigue, presyncope, mild shortness of breath, and possibly chest pain or hypotension commonly occur as symptoms in atrial flutter [4]
Atrioventricular Block [5] This is a poorly-recognized cause of atrioventricular conduction abnormality leading to syncope and can be fatal because it can lead to sudden cardiac death [5]
References
  1. SHIM SH, PARK SY, MOON SN, OH JH, LEE JY, KIM HH, HAN JW, LEE SJ. Baseline heart rate variability in children and adolescents with vasovagal syncope Korean J Pediatr [online] 2014 Apr, 57(4):193-198 [viewed 22 June 2014] Available from: doi:10.3345/kjp.2014.57.4.193
  2. ARTHUR W. The pathophysiology of common causes of syncope. [online] 2000 December, 76(902):750-753 [viewed 22 June 2014] Available from: doi:10.1136/pmj.76.902.750
  3. ROBERTS JD, GOLLOB MH. A Contemporary Review on the Genetic Basis of Atrial Fibrillation Methodist Debakey Cardiovasc J [online] 2014, 10(1):18-24 [viewed 22 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4051329
  4. FOY S, LEVIS JT. ECG Diagnosis: Type I Atrial Flutter Perm J [online] 2014, 18(2):e128 [viewed 22 June 2014] Available from: doi:10.7812/TPP/13-132
  5. ZAHID M, ARORA S. Reverse Wenckebach "pseudo-supernormal" conduction or paroxysmal atrioventricular block J Cardiovasc Dis Res [online] 2012, 3(3):225-227 [viewed 22 June 2014] Available from: doi:10.4103/0975-3583.98898

Investigations - for Diagnosis

Fact Explanation
Electrocardiogram [1] [2] [3] The diagnosis of sick sinus syndrome requires electrocardiographic findings of bradyarrhythmias, such as sinus bradycardia, sinoatrial pause of three seconds or more, sinoatrial exit block, or sinus arrest. But findings often are normal in patients with sick sinus syndrome, particularly early in the disease course. Even though bradyarrhythmias are required for the diagnosis, supraventricular tachyarrhythmias are present in around 50 % of patients with sick sinus syndrome. Episodes of alternating tachyarrhythmias and bradyarrhythmias are known as tachycardia- bradycardia, or tachy-brady, syndrome. The most common tachyarrhythmias are atrial fibrillation or flutter and these tachyarrhythmias are more common in older patients with advanced sinoatrial nodal disease in whom sino - atrial node fibrosis is seen. [1] [2] [3]
24 hour Holter monitoring [2] [3] When electrocardiography can not yield a diagnosis, prolonged cardiac monitoring should done. This can be done in the hospital via telemetry monitoring or on an outpatient basis with a 24- to 48-hour Holter monitor. It can be repeated if the diagnosis is uncertain. [2] [3]
external continuous or event monitors [3] If clinical suspicion of arrhythmia remains high and Holter monitoring results are not conclusive, external continuous or event monitors can be used in patients for for weeks at a time [3]
implantable loop recorder [4] If above investigations are inconclusive this can be done for months at a time. [4]
Electrophysiologic studies [3] These are useful in the evaluation of sick sinus syndrome in whom sick sinus syndrome is strongly suspected but no arrhythmia has been demonstrated that correlates with symptoms after prolonged cardiac monitoring [3]
exercise treadmill testing [5] It's been found that 38 to 57% of patients with known sick sinus syndrome were unable to achieve a maximal heart rate of 120 beats per minute. This inadequate response to exercise suggests chronotropic incompetence that occurs in persons with sick sinus syndrome, but there are no well-validated standards for diagnosing sick sinus syndrome with this. [5]
Carotid sinus massage or pressure [2] When results in a sinoatrial pause for more than three seconds is also suggestive, but not diagnostic, of sick sinus syndrome. [2]
References
  1. GREGORATOS G.. Sick Sinus Syndrome. Circulation [online] 2003 November, 108(20):143e-144 [viewed 22 June 2014] Available from: doi:10.1161/​01.CIR.0000102938.55119.EC
  2. ADáN V, CROWN LA. Diagnosis and treatment of sick sinus syndrome. Am Fam Physician [online] 2003 Apr 15, 67(8):1725-32 [viewed 22 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12725451
  3. TAN MP, KENNY RA. Cardiovascular Assessment of Falls in Older People Clin Interv Aging [online] 2006 Mar, 1(1):57-66 [viewed 22 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2682455
  4. BLOCH THOMSEN P. E., JONS C., RAATIKAINEN M. J. P., MOERCH JOERGENSEN R., HARTIKAINEN J., VIRTANEN V., BOLAND J., ANTTONEN O., GANG U. J., HOEST N., BOERSMA L. V. A., PLATOU E. S., BECKER D., MESSIER M. D., HUIKURI H. V.. Long-Term Recording of Cardiac Arrhythmias With an Implantable Cardiac Monitor in Patients With Reduced Ejection Fraction After Acute Myocardial Infarction: The Cardiac Arrhythmias and Risk Stratification After Acute Myocardial Infarction (CARISMA) Study. Circulation [online] December, 122(13):1258-1264 [viewed 22 June 2014] Available from: doi:10.1161/CIRCULATIONAHA.109.902148
  5. HOLDEN W, MCANULTY JH, RAHIMTOOLA SH. Characterisation of heart rate response to exercise in the sick sinus syndrome. Br Heart J [online] 1978 Aug, 40(8):923-930 [viewed 22 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC483509
  6. DEVELOPED IN COLLABORATION WITH, EUROPEAN HEART RHYTHM ASSOCIATION (EHRA), HEART FAILURE ASSOCIATION (HFA), AND HEART RHYTHM SOCIETY (HRS), ENDORSED BY THE FOLLOWING SOCIETIES, EUROPEAN SOCIETY OF EMERGENCY MEDICINE (EUSEM), EUROPEAN FEDERATION OF INTERNAL MEDICINE (EFIM), EUROPEAN UNION GERIATRIC MEDICINE SOCIETY (EUGMS), AMERICAN GERIATRICS SOCIETY (AGS), EUROPEAN NEUROLOGICAL SOCIETY (ENS), EUROPEAN FEDERATION OF AUTONOMIC SOCIETIES (EFAS), AMERICAN AUTONOMIC SOCIETY (AAS), AUTHORS/TASK FORCE MEMBERS, MOYA A, SUTTON R, AMMIRATI F, BLANC JJ, BRIGNOLE M, DAHM JB, DEHARO JC, GAJEK J, GJESDAL K, KRAHN A, MASSIN M, PEPI M, PEZAWAS T, GRANELL RR, SARASIN F, UNGAR A, VAN DIJK JG, WALMA EP, WIELING W, EXTERNAL CONTRIBUTORS, ABE H, BENDITT DG, DECKER WW, GRUBB BP, KAUFMANN H, MORILLO C, OLSHANSKY B, PARRY SW, SHELDON R, SHEN WK, ESC COMMITTEE FOR PRACTICE GUIDELINES (CPG), VAHANIAN A, AURICCHIO A, BAX J, CECONI C, DEAN V, FILIPPATOS G, FUNCK-BRENTANO C, HOBBS R, KEARNEY P, MCDONAGH T, MCGREGOR K, POPESCU BA, REINER Z, SECHTEM U, SIRNES PA, TENDERA M, VARDAS P, WIDIMSKY P, DOCUMENT REVIEWERS, AURICCHIO A, ACARTURK E, ANDREOTTI F, ASTEGGIANO R, BAUERSFELD U, BELLOU A, BENETOS A, BRANDT J, CHUNG MK, CORTELLI P, DA COSTA A, EXTRAMIANA F, FERRO J, GORENEK B, HEDMAN A, HIRSCH R, KALISKA G, KENNY RA, KJELDSEN KP, LAMPERT R, MøLGARD H, PAJU R, PUODZIUKYNAS A, RAVIELE A, ROMAN P, SCHERER M, SCHONDORF R, SICARI R, VANBRABANT P, WOLPERT C, ZAMORANO JL. Guidelines for the diagnosis and management of syncope (version 2009): The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC) Eur Heart J [online] 2009 Nov, 30(21):2631-2671 [viewed 22 June 2014] Available from: doi:10.1093/eurheartj/ehp298

Investigations - Fitness for Management

Fact Explanation
Echocardiography [1] Congestive cardiac failure can be developed as a consequence of pacemaker implantation. This is thought to be due to the abnormal contraction pattern seen during ventricular (DDDR) pacing which may lead to left ventricular remodelling, decreased left ventricular function, and dilatation of the left atrium. To exclude heart failure before pacing, this is done [1]
References
  1. NIELSEN J. C., ANDERSEN H. R., THOMSEN P. E. B., THUESEN L., MORTENSEN P. T., VESTERLUND T., PEDERSEN A. K.. Heart Failure and Echocardiographic Changes During Long-term Follow-up of Patients With Sick Sinus Syndrome Randomized to Single-Chamber Atrial or Ventricular Pacing. Circulation [online] 1998 March, 97(10):987-995 [viewed 22 June 2014] Available from: doi:10.1161/​01.CIR.97.10.987

Investigations - Followup

Fact Explanation
Electrocardiogram [1] [2] [3] To look for the development of any other arrhythmias such as atrial fibrillation, atrial flutter or supraventricular tachyarrhythmias or atrioventricular block. [1] [4]
Echocardiography [4] [5] To assess ejection fraction for the development of possible congestive cardiac failure which can also be developed as a consequence of pacemaker implantation. This is thought to be due to the abnormal contraction pattern seen during ventricular (DDDR) pacing which may lead to left ventricular remodelling, decreased left ventricular function, and dilatation of the left atrium [4] [5]
Clotting profile [3] Patients with SSS are started on Warfarin to counteract thrombo-embolism, therefore monitoring with clotting profile should be done. [3]
References
  1. GREGORATOS G.. Sick Sinus Syndrome. Circulation [online] 2003 November, 108(20):143e-144 [viewed 22 June 2014] Available from: doi:10.1161/​01.CIR.0000102938.55119.EC
  2. ADáN V, CROWN LA. Diagnosis and treatment of sick sinus syndrome. Am Fam Physician [online] 2003 Apr 15, 67(8):1725-32 [viewed 22 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12725451
  3. TAN MP, KENNY RA. Cardiovascular Assessment of Falls in Older People Clin Interv Aging [online] 2006 Mar, 1(1):57-66 [viewed 22 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2682455
  4. ANDERSEN H. R., NIELSEN J. C., THOMSEN P. E. B., THUESEN L., VESTERLUND T., PEDERSEN A. K., MORTENSEN P. T.. Atrioventricular Conduction During Long-Term Follow-Up of Patients With Sick Sinus Syndrome. Circulation [online] 1998 September, 98(13):1315-1321 [viewed 22 June 2014] Available from: doi:10.1161/​01.CIR.98.13.1315
  5. NIELSEN J. C., ANDERSEN H. R., THOMSEN P. E. B., THUESEN L., MORTENSEN P. T., VESTERLUND T., PEDERSEN A. K.. Heart Failure and Echocardiographic Changes During Long-term Follow-up of Patients With Sick Sinus Syndrome Randomized to Single-Chamber Atrial or Ventricular Pacing. Circulation [online] 1998 March, 97(10):987-995 [viewed 22 June 2014] Available from: doi:10.1161/​01.CIR.97.10.987
  6. RIAHI S., NIELSEN J. C., HJORTSHOJ S., THOMSEN P. E. B., HOJBERG S., MOLLER M., DALSGAARD D., NIELSEN T., ASKLUND M., FRIIS E. V., CHRISTENSEN P. D., SIMONSEN E. H., ERIKSEN U. H., JENSEN G. V. H., SVENDSEN J. H., TOFF W. D., HEALEY J. S., ANDERSEN H. R.. Heart failure in patients with sick sinus syndrome treated with single lead atrial or dual-chamber pacing: no association with pacing mode or right ventricular pacing site. Europace [online] December, 14(10):1475-1482 [viewed 22 June 2014] Available from: doi:10.1093/europace/eus069

Investigations - Screening/Staging

Fact Explanation
Electrocardiogram [1] [2] [3] To demonstrate the possible variants of SSS such as sinus bradycardia, sinoatrial pause of three seconds or more, sinoatrial exit block, or sinus arrest, tachy-brady, syndrome, atrial fibrillation or flutter or atrioventricular block. [1] [2] [3]
References
  1. GREGORATOS G.. Sick Sinus Syndrome. Circulation [online] 2003 November, 108(20):143e-144 [viewed 22 June 2014] Available from: doi:10.1161/​01.CIR.0000102938.55119.EC
  2. ADáN V, CROWN LA. Diagnosis and treatment of sick sinus syndrome. Am Fam Physician [online] 2003 Apr 15, 67(8):1725-32 [viewed 22 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12725451
  3. TAN MP, KENNY RA. Cardiovascular Assessment of Falls in Older People Clin Interv Aging [online] 2006 Mar, 1(1):57-66 [viewed 22 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2682455

Management - General Measures

Fact Explanation
Patient education [4] Patients need to be educated on the nature, course and prognosis of the disease, exercise, as well as special precautions to be done after pacemaker implantation Ex: They cannot undergo magnetic resonance imaging.[4]
Patient identification [4] A bracelet/ hand band or diagnosis card should be provided to identify patients in emergency situations such as during a syncope [4]
Treatment of congestive cardiac failure [1] [2] [3] Treatment regime for heart failure including diuretics are needed if congestive cardiac failure develops. digitalis can be used if there's bradycardia associated with congestive cardiac failure but should be vigilant as it can worsen sinoatrial dysfunction [2] [3] [6]
Anticoagulant therapy [5] As these patients are at risk of thromboembolism due to atrial fibrillation, anticoagulation with Warfarin is needed [5]
Diet [4] There shouldn't be any dietary limitations except in heart failure where low salt diet is recommended. [4]
Exercise [4] They should not do strenuous activities but shouldn't limit their normal day to day activities. [4]
References
  1. GREGORATOS G.. Sick Sinus Syndrome. Circulation [online] 2003 November, 108(20):143e-144 [viewed 22 June 2014] Available from: doi:10.1161/​01.CIR.0000102938.55119.EC
  2. NIELSEN J. C., ANDERSEN H. R., THOMSEN P. E. B., THUESEN L., MORTENSEN P. T., VESTERLUND T., PEDERSEN A. K.. Heart Failure and Echocardiographic Changes During Long-term Follow-up of Patients With Sick Sinus Syndrome Randomized to Single-Chamber Atrial or Ventricular Pacing. Circulation [online] 1998 March, 97(10):987-995 [viewed 22 June 2014] Available from: doi:10.1161/​01.CIR.97.10.987
  3. RIAHI S., NIELSEN J. C., HJORTSHOJ S., THOMSEN P. E. B., HOJBERG S., MOLLER M., DALSGAARD D., NIELSEN T., ASKLUND M., FRIIS E. V., CHRISTENSEN P. D., SIMONSEN E. H., ERIKSEN U. H., JENSEN G. V. H., SVENDSEN J. H., TOFF W. D., HEALEY J. S., ANDERSEN H. R.. Heart failure in patients with sick sinus syndrome treated with single lead atrial or dual-chamber pacing: no association with pacing mode or right ventricular pacing site. Europace [online] December, 14(10):1475-1482 [viewed 22 June 2014] Available from: doi:10.1093/europace/eus069
  4. WOOD M. A.. Cardiac Pacemakers From the Patient's Perspective. [online] 2002 May, 105(18):2136-2138 [viewed 22 June 2014] Available from: doi:10.1161/​01.CIR.0000016183.07898.90
  5. KRISTENSEN L, NIELSEN JC, MORTENSEN PT, PEDERSEN OL, PEDERSEN AK, ANDERSEN HR. Incidence of atrial fibrillation and thromboembolism in a randomised trial of atrial versus dual chamber pacing in 177 patients with sick sinus syndrome Heart [online] 2004 Jun, 90(6):661-666 [viewed 22 June 2014] Available from: doi:10.1136/hrt.2003.016063
  6. RUBENSTEIN J. J., SCHULMAN C. L., YURCHAK P. M., DESANCTIS R. W.. Clinical Spectrum of the Sick Sinus Syndrome. Circulation [online] 1972 July, 46(1):5-13 [viewed 22 June 2014] Available from: doi:10.1161/​01.CIR.46.1.5

Management - Specific Treatments

Fact Explanation
No treatment If there's only bradycardia treatment may not be needed. [2]
permanent pacemaker implantation [3], [4], [5] [6] [7] Implantation is indicated if documented symptomatic bradycardia with frequent sinus pauses that produce symptoms, Symptomatic chronotropic incompetence, Symptomatic sinus bradycardia caused by medication required for medical condition. Implantation is considered reasonable if significant symptoms of bradycardia and documented heart rate less than 40 beats per minute without documentation of bradycardia during symptoms, syncope of unexplained origin with dysfunction of sinoatrial node discovered or provoked in electrophysiologic studies. Implantation may be considered minimally symptomatic patients with chronic heart rate less than 40 beats per minute while awake. with regard to the pacing mode in SSS, The results of 4 randomized studies were in favor of atrial or dual, rather than ventricular, in patients with SSS. They also showed that patients paced with atrial or dual mode had a significantly lower incidence of atrial fibrillation, stroke, and pacemaker syndrome than those paced with ventricular mode [3]
Anti arrhythmic drug treatment [2] Therapy for tachyarrhythmia with digitalis and/or other antiarrhythmic agents may cause marked bradycardia and syncope therefore should be used with caution. Atropine, given for bradycardia, may promote the appearance of tachyarrhythmia. Therefore drugs are used only with caution [2]
Catheter Ablation therapy [1] Radiofrequency catheter ablation for atrial fibrillation in patients with SSS and a permanent pacemaker is found to be safe, but these patients have an increased risk of recurrence of atrial fibrillation [1]
References
  1. WUTZLER A, HUEMER M, PARWANI AS, BLASCHKE F, HAVERKAMP W, BOLDT LH. Contact force mapping during catheter ablation for atrial fibrillation: procedural data and one-year follow-up Arch Med Sci [online] 2014 May 12, 10(2):266-272 [viewed 22 June 2014] Available from: doi:10.5114/aoms.2014.42578
  2. RUBENSTEIN J. J., SCHULMAN C. L., YURCHAK P. M., DESANCTIS R. W.. Clinical Spectrum of the Sick Sinus Syndrome. Circulation [online] 1972 July, 46(1):5-13 [viewed 22 June 2014] Available from: doi:10.1161/​01.CIR.46.1.5
  3. VARDAS P. E., SIMANTIRAKIS E. N., KANOUPAKIS E. M.. New Developments in Cardiac Pacemakers. Circulation [online] December, 127(23):2343-2350 [viewed 22 June 2014] Available from: doi:10.1161/​CIRCULATIONAHA.112.000086
  4. RISGAARD B, BUNDGAARD H, JABBARI R, HAUNSø S, WINKEL BG, TFELT-HANSEN J. Pacemaker implantation in a patient with brugada and sick sinus syndrome World J Cardiol [online] 2013 Mar 26, 5(3):65-67 [viewed 22 June 2014] Available from: doi:10.4330/wjc.v5.i3.65
  5. GREGORATOS G.. Sick Sinus Syndrome. Circulation [online] 2003 November, 108(20):143e-144 [viewed 22 June 2014] Available from: doi:10.1161/​01.CIR.0000102938.55119.EC
  6. MASUMOTO H. Long-term clinical performance of AAI pacing in patients with sick sinus syndrome: a comparison with dual-chamber pacing. Europace [online] 2004 September, 6(5):444-450 [viewed 22 June 2014] Available from: doi:10.1016/j.eupc.2004.05.003
  7. WOOD M. A.. Cardiac Pacemakers From the Patient's Perspective. [online] 2002 May, 105(18):2136-2138 [viewed 22 June 2014] Available from: doi:10.1161/​01.CIR.0000016183.07898.90