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Treatment of Persistent Sinus Bradycardia With Intermitten Sypmtomp
Treatment of Persistent Sinus Bradycardia With Intermitten Sypmtomp
doi:10.1093/europace/eup014
Received 15 October 2008; accepted after revision 14 January 2009; online publish-ahead-of-print 12 February 2009
There is uncertainty in the aetiology of syncope in subjects with persistent sinus bradycardia (SB) (sick sinus syndrome). The results of patho-
physiological studies suggest a reflex origin of syncope in the vast majority of subjects with SB. From a nosological point of view, ‘syndrome’ is
defined as the association of signs and symptoms that have a pathophysiological correlation. Since in most cases the causal relationship
between syncope and persistent SB appears very weak, ‘reflex syncope with associated SB’ appears to be the most appropriate diagnosis.
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Keywords Carotid sinus massage † Sick sinus syndrome † Sinus bradycardia † Syncope † Tilt testing
The sick sinus syndrome is a descriptive term that refers to a con- with those used in the same guidelines for neurally mediated
stellation of signs and symptoms defining sinus node dysfunction in syncope. Indeed, in the European guidelines, ‘Recurrent severe
a clinical setting. The most frequent electrocardiographic (ECG) vasovagal syncope in patients who show prolonged asystole
sign is persistent sinus bradycardia (SB), (sinus rate , 50 bpm). during ECG recording’ is a class IIa indication, and in the American
Although persistent clinical manifestations of bradycardia (due to guidelines, ‘Significantly symptomatic neurocardiogenic syncope
the consequent reduction in cerebral and peripheral perfusion) associated with bradycardia documented spontaneously’ is a class
such as subtle symptoms of fatigue, irritability, lassitude, inability IIb indication.
to concentrate, lack of interest, forgetfulness, and dizziness can
be expected, it is more difficult to explain intermittent symptoms
(syncope and pre-syncope), which are present in about a half of Pathophysiology of syncope in
the patients affected by sinus node dysfunction requiring hospital
assistance.1,2 Although persistent symptomatic bradycardia clearly
subjects with sinus bradicardia
defines sick sinus syndrome, the meaning of intermittent severe The possible role of autonomic factors in the genesis of signs and
SB or sinus arrest is less clear. Indeed, the same event (i.e. intermit- symptoms characterizing sick sinus syndrome has been suggested
tent symptomatic sinus arrest) may be diagnosed by one physician for a long time.
as sick sinus syndrome and by another as cardio-inhibitory reflex Two studies5,6 have specifically evaluated the relationship
syndrome. On the other hand, the same syncope may be diag- between syncope and abnormal reflexes in patients with SB.
nosed as reflex if not documented, whereas it may be diagnosed Brignole et al. 5 performed head-up tilt testing (HUT) and carotid
as sick sinus syndrome if there is fortuitous documentation of a sinus massage (CSM) with the method of symptoms in 35 patients
pause. with SB and syncope and compared the results with those
This uncertainty of the aetiology of syncope in subjects with SB obtained in 35 patients with normal sinus rate who were affected
is also reflected in the recommendations for pacing therapy of the by syncope of uncertain origin. The percentage of positive HUT in
European3 and American guidelines.4 Indeed, in the European the subjects with SB was high (54%): higher than that recorded in
guidelines ‘Syncope with sinus node disease . . . .spontaneously the subjects with syncope of uncertain origin (26%). The percen-
occurring . . . ’ is considered among class I indications, and in the tage of positive CSM in the subjects with SB was also high (60%)
American guidelines, ‘Syncope of unexplained origin when clinically and similar to that observed in patients with syncope of uncertain
significant abnormalities of sinus node function . . . ’ is considered origin (63%). Thus, an abnormal neural reflex played a major role
among class IIa indications. These definitions seem to overlap in causing syncope in subjects with SB. In order to evaluate
* Corresponding author. Tel: þ39 51 6838219, Fax: þ39 51 6838471, Email: p.alboni@ausl.fe.it
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org.
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