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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 64, NO. 6, 2014 ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2014.05.029 EDITORIAL COMMENT Sick Sinus Syndrome Synopsis* Gordon A. Ewy, MD S ick sinus syndrome (SSS) is a term used for a is most common in the elderly, its symptoms may be variety of cardiac arrhythmias, occurring pre- attributed to the aging process rather than to a dis- dominantly in the elderly, that result from a ease. One of the hallmarks of aging is the progressive senescent sinus node. Because the sinus node is the loss of cells, and this loss of cells in the sinus node is normal pacemaker of the heart, its dysfunction is a a commonly reported pathological finding in patients cause for concern. Although the major problem is with SSS. The frequent lack of an effective escape failure of the sinoatrial node, the symptoms would rhythm emphasizes the diffuse nature of the con- be uncommon were it not for the diffuse nature of duction system disease. Because the sinus node gets the dysfunction, accounting for the frequent failure its blood supply from a branch of a coronary artery, of escape or rescue rhythms. Accordingly, SSS is char- SSS also can be caused by atherosclerosis and may acterized, not only by sinus node malfunction, result- be associated with angina. The syndrome can be ing in intermittent sinus pauses and rare sinus arrest, accompanied by a variety of other supraventricular but also by inappropriate and often intermittent arrhythmias. Although the rescue rhythms are usu- bradycardia, tachycardia, and the frequent alterna- ally atrial, the association of atrioventricular nodal tion between the 2 conditions (tachycardia-brady- disease is not uncommon. cardia syndrome) (1,2). Clinically significant SSS often requires pacemaker When sinus node dysfunction is associated with implantation. Ferrer (5) pointed out in 1982 that one- symptoms, or prolonged periods of asystole, it is half of the 60,000 pacemakers implanted were for referred to as the sick sinus syndrome. Although Dr. SSS. By 2006, SSS was one of the most common rea- Short (3) had previously published on “The Syndrome sons for the escalating number of pacemaker im- of Alternating Bradycardia and Tachycardia,” Dr. plants (6). Ferrer (4) was evidently the first, in 1968, to use the In describing the epidemiology of SSS, Jensen et term sick sinus syndrome to describe the sluggish re- al. (7) in this issue of the Journal confirmed that SSS turn of sinoatrial nodal function in patients following was associated with the increasing age of the popu- electrical cardioversion. lation, predicted to produce a steady increase in the Sick sinus syndrome is generally a disease of aging. incidence of SSS and, thus, in the need for permanent It is uncommon in children. If present in children, it pacemaker implantation, estimating that by 2060, was usually acquired post-operatively as a result of there will be more than 170,000 new cases of SSS trauma to the atrium during cardiac surgery to correct per year. congenital heart defects. SEE PAGE 531 A characteristic feature of SSS is that the heart does not respond normally to stimuli that should produce increased heart rates, such as exercise. Because SSS The investigators of this study identified SSS by the International Classification of Disease-revision 9-Clinical *Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology. From the University of Arizona Sarver Heart Center, Tucson, Arizona. Modification (ICD-9-CM) code 427.81, which incorporates SSS, sinoatrial node dysfunction, tachycardia-bradycardia syndrome, and persistent sinus bradycardia. They considered SSS to be pre- Dr. Ewy has reported that he has no relationships relevant to the sent if the medical record included a diagnosis of contents of this paper to disclose. SSS and symptoms or signs consistent with SSS 540 Ewy JACC VOL. 64, NO. 6, 2014 AUGUST 12, 2014:539–40 Sick Sinus Syndrome: Synopsis (e.g., syncope, dizziness, bradycardia, sinus pauses), An asystole response of 3 or more seconds to carotid with no evidence of other conditions responsible for sinus pressure is strongly suggestive of SSS and an the episode, such as atrioventricular block or medi- indication for a permanent pacemaker if the patient cation use (7). These investigators confirmed that the has a history of syncope (8). incidence of SSS increased with age, but found that The definitive diagnosis is often made by ambu- blacks had a lower risk than whites. They reported latory monitoring or by electrophysiological studies. that the incidence of SSS was associated with greater Modern ambulatory monitoring alternatives are often body mass index, greater height, longer QRS interval, essential to this diagnosis. The increasing sophisti- lower heart rate, and prevalent hypertension, right cation, diagnostic ability, and surgical skills of the bundle branch block, and cardiovascular disease (7). modern electrophysiologists make the diagnosis easy The SSS may be difficult to diagnosis, because and therapy of patients with SSS effective. Jensen initially, the symptoms may be mild and very inter- et al. (7) predict that with the aging of our population, mittent. When the patient presents with symptoms SSS will be a major factor in increasing the need for consistent with SSS, a detailed history of medica- permanent pacemakers. This fact will drive research tions, including alternative medications, is essential. into more effective approaches to the diagnosis of In addition, it is rare, but the patient may be taking the SSS and into decreasing the size and type of the same medication prescribed by 2 different phy- permanent pacemakers, as well as increasing the sicians: one by a generic name and the other by a sophistication of future permanent pacemakers. trade name, such as metoprolol and Toprol-XL, or digoxin and Lanoxin, where known side effects of REPRINT REQUESTS AND CORRESPONDENCE: Dr. overdose are arrhythmias consistent with SSS. Gordon A. Ewy, Department of Medicine, University The physical examination and the electrocardio- of Arizona Sarver Heart Center, 932 West San Martin gram are important, including performing carotid si- Drive, Tucson, Arizona 85704. E-mail: gaewy1933@ nus pressure, while observing the electrocardiogram. gmail.com. REFERENCES 1. Ewy GA. Management of bradydysrhythmias and conduction disturbances. In: Ewy GA, Bressler R, editors. Cardiovascular Drugs and the Management of Heart Disease. New York, NY: Raven Press, 1982:441–62. 2. Gregoratos G. Sick sinus syndrome. Circulation 5. Ferrer MI. The etiology and natural history of sinus node disorders. Arch Intern Med 1982;142: 371–2. 6. Birnie D, Williams K, Guo A, et al. Reasons for escalating pacemaker implants. J Am Coll Cardiol 2006;98:93–7. 2003;108:e143–4. 7. Jensen PN, Gronroos NN, Chen LY, et al. Inci- 3. Short DS. The syndrome of alternating bradycardia and tachycardia. Brit Heart J 1954;16: 208–14. dence of and risk factors for sick sinus syndrome in the general population. J Am Coll Cardiol 2014; 64:531–8. 4. Ferrer MI. The sick sinus syndrome in atrial disease. JAMA 1967;206:625–46. 8. Epstein AE, DiMarco JP, Ellenbogen KA, 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). J Am Coll Cardiol 2008; 51:e1–62. KEY WORDS cardiac arrest, passive ventilation, prevention, ventricular fibrillation