What are the guideline sources, guidelines and references for Sick sinus syndrome ?
Guideline sources The following summarized guidelines for the evaluation and management of sick sinus syndrome are prepared by our editorial team based on guidelines from the Heart Rhythm Society (HRS 2022), the Japanese Heart Rhythm Society (JHRS/JCS 2022; 2021), the European Society of Cardiology (ESC 2021; 2018), the Infectious Diseases Society of America (IDSA/ACR/AAN 2021), the American Heart Association (AHA 2020), the American Heart Association (AHA/HRS/ACC 2019; 2013), the Wilderness Medical Society (WMS 2019), and the Canadian Association of Poison Control Centres (CAPCC/ESICM/CAEP/AAPCC/SCCM/CPS/EAPCCT/ESEM/CCCS/ACMT 2017). 1 2 3 4 5 6 7 8 9 10 11 Guidelines 1. Diagnostic investigations History and physical examination: elicit a comprehensive history and perform a physical examination in patients with suspected bradycardia. B Resting electrocardiogram: obtain a 12-lead ECG to document rhythm, rate, and conduction and to screen for structural heart diseases or systemic illnesses in patients with suspected bradycardia. B https://web.pathway.md/diseases/recqRXp3bvdVQRp0w 1/10 6/24/23, 3:06 PM Sick sinus syndrome Pathway Exercise electrocardiogram: As per ESC 2021 guidelines: Obtain exercise testing in patients experiencing symptoms suspicious of bradycardia during or immediately after exertion. B Consider obtaining exercise testing to confirm the diagnosis in patients with suspected chronotropic incompetence. C As per ACC 2019 guidelines: Consider obtaining exercise ECG testing to ascertain the diagnosis and provide information on prognosis in patients with suspected chronotropic incompetence. C Consider obtaining exercise ECG testing in patients with exercise-related symptoms suspicious for bradycardia. C Ambulatory ECG monitoring: As per ESC 2021 guidelines, obtain ambulatory ECG monitoring to correlate rhythm disturbances with symptoms in patients with suspected bradycardia. B As per ACC 2019 guidelines, consider obtaining cardiac rhythm monitoring in the evaluation of patients with documented or suspected bradycardia to establish a correlation between HR with symptoms, with the specific type of cardiac monitor chosen based on the frequency and nature of symptoms, as well as patient preferences. B Diagnostic imaging: As per ESC 2021 guidelines: Obtain cardiac imaging to evaluate for structural heart disease, determine LV systolic function, and diagnose potential causes of conduction disturbances in patients with suspected or documented symptomatic bradycardia. B Consider obtaining multimodality imaging (cardiovascular MRI, CT, or positron emission tomography) for myocardial tissue characterization in the diagnosis of specific pathologies associated with conduction abnormalities requiring pacemaker implantation, particularly in patients aged < 60 years. C As per ACC 2019 guidelines, consider obtaining a TTE in selected patients with suspected structural heart disease presenting with bradycardia. C Show 2 more Laboratory testing: As per ESC 2021 guidelines, obtain specific laboratory tests (such as thyroid function tests, Lyme titer, digitalis level, potassium, calcium, and pH), in addition to pre-implantation laboratory tests, in patients with clinical suspicion for potential underlying causes of reversible bradycardia. B As per ACC 2019 guidelines, consider obtaining laboratory tests (such as thyroid function tests, Lyme titer, potassium, and pH) based on clinical suspicion of a potential underlying cause in patients with bradycardia. C Sleep evaluation: https://web.pathway.md/diseases/recqRXp3bvdVQRp0w 2/10 6/24/23, 3:06 PM Sick sinus syndrome Pathway As per ESC 2021 guidelines, assess for sleep apnea syndrome in patients with symptoms of sleep apnea syndrome or severe bradycardia during sleep. B As per ACC 2019 guidelines: Assess for symptoms of sleep apnea syndrome and obtain subsequent confirmatory testing directed by clinical suspicion in patients with documented or suspected bradycardia during sleep. B Consider screening for sleep apnea syndrome in patients previously received or being considered for a permanent pacemaker for bradycardia. C 2. Diagnostic procedures Implantable loop recorder: As per ESC 2021 guidelines, obtain long-term ambulatory monitoring with an implantable loop recorder in patients with infrequent (< 1 per month) unexplained syncope or other symptoms suspected to be caused by bradycardia, if the initial comprehensive evaluation is nondiagnostic. A As per ACC 2019 guidelines, consider obtaining long-term ambulatory monitoring with an implantable cardiac monitor in patients with infrequent symptoms (> 30 days between symptoms) suspected to be caused by bradycardia, if the initial noninvasive evaluation is nondiagnostic. C Electrophysiology study: As per ESC 2021 guidelines, consider obtaining an electrophysiology study in patients with syncope and sinus bradycardia if noninvasive tests have failed to show a correlation between syncope and bradycardia. C As per ACC 2019 guidelines, consider obtaining an electrophysiology study in selected patients with symptoms suspected to be attributable to bradycardia for diagnosis and elucidation of the bradycardia mechanism, if the initial noninvasive evaluation is nondiagnostic. C Show 3 more 3. Medical management Shared decision-making: engage patients with symptomatic bradycardia in a shared decision- making process for treatment decisions and base treatment decisions on the best available evidence and the patient's goals of care, preferences, and values. B Addressing reversible causes: Evaluate for and treat reversible causes in symptomatic patients presenting with SND. B Direct treatment at eliminating or mitigating the offending condition first in patients presenting with symptomatic SND secondary to a reversible cause. B Atropine: https://web.pathway.md/diseases/recqRXp3bvdVQRp0w 3/10 6/24/23, 3:06 PM Sick sinus syndrome Pathway As per JCS 2022 guidelines, consider administering IV atropine as a bridging method for pacemaker therapy in patients with bradycardia attributable to SND. C As per ACC 2019 guidelines, consider administering atropine to increase sinus rate in patients with SND associated with symptoms or hemodynamic compromise. C Beta-adrenergic agonists: As per JCS 2022 guidelines, consider administering IV sympathomimetics as a bridging method for pacemaker therapy in patients with bradycardia attributable to SND. C As per AHA 2020 guidelines, consider administering IV adrenergic agonists with rate- accelerating effects (such as epinephrine) in patients with bradycardia unresponsive to atropine. C As per ACC 2019 guidelines, consider administering isoproterenol, dopamine, dobutamine, or epinephrine to increase HR and improve symptoms in patients with SND associated with symptoms or hemodynamic compromise at a low likelihood of coronary ischemia. C Theophylline and aminophilline: As per JCS 2022 guidelines, consider administering oral theophylline in patients with bradycardia attributable to sick sinus syndrome refusing or ineligible for pacemaker implantation. C As per ACC 2019 guidelines, consider administering a trial of oral theophylline to increase HR, improve symptoms, and help determine the potential effects of permanent pacing in patients with symptoms likely attributable to SND. C Show 2 more Phosphodiesterase-3 inhibitors: consider administering oral cilostazol in patients with bradycardia attributable to sick sinus syndrome refusing or ineligible for pacemaker implantation. C 4. Therapeutic procedures Temporary pacing, transvenous: As per ESC 2021 guidelines, perform temporary transvenous pacing in patients with hemodynamic-compromising bradyarrhythmia refractory to IV chronotropic drugs. B Show 3 more As per AHA 2020 guidelines, consider performing temporary transvenous pacing to increase HR and improve symptoms in patients with persistent hemodynamically unstable bradycardia refractory to medical therapy. C As per HRS/AHA/ACC 2019 guidelines: Consider performing temporary transvenous pacing to increase HR and improve symptoms until a permanent pacemaker is placed or the bradycardia resolves in patients with persistent hemodynamically unstable SND refractory to medical therapy. C https://web.pathway.md/diseases/recqRXp3bvdVQRp0w 4/10 6/24/23, 3:06 PM Sick sinus syndrome Pathway Do not perform temporary transvenous pacing in patients with SND with minimal and/or infrequent symptoms without hemodynamic compromise. D Temporary pacing, transcutaneous: As per ESC 2021 guidelines, consider performing transcutaneous pacing in patients with hemodynamic-compromising bradyarrhythmia when temporary transvenous pacing is not possible or available. C As per AHA 2020 guidelines, consider performing transcutaneous pacing in patients with bradycardia unresponsive to atropine while the patient is prepared for emergent transvenous temporary pacing. C As per HRS/AHA/ACC 2019 guidelines: Consider performing temporary transcutaneous pacing to increase HR and improve symptoms until a temporary transvenous or permanent pacemaker is placed or the bradycardia resolves in patients with SND with severe symptoms or hemodynamic compromise. C Do not perform temporary transcutaneous pacing in patients with SND with minimal and/or infrequent symptoms without hemodynamic compromise. D Permanent pacing, indications, asymptomatic bradycardia: As per ESC 2021 guidelines: Do not perform pacing in patients with bradyarrhythmias related to asymptomatic SND or due to correctable and preventable transient causes. D Consider performing cardiac pacing to reduce recurrent episodes of syncope in patients with asymptomatic pauses > 6 sec due to sinus arrest. C As per JHRS/JCS 2021 guidelines, consider performing permanent pacing in asymptomatic patients with sinoatrial block or sinus arrest. C As per HRS/AHA/ACC 2019 guidelines, do not perform permanent pacing in patients with asymptomatic sinus bradycardia or sinus pauses secondary to physiologically elevated parasympathetic tone. D Show 2 more As per HRS/AHA/ACC 2013 guidelines: Do not perform permanent pacing in patients with asymptomatic SND. D Consider performing permanent pacing in patients with asymptomatic sinus bradycardia after biventricular repair of congenital heart disease with a resting HR < 40 bpm or pauses in ventricular rate > 3 sec. C Permanent pacing, indications, symptomatic bradycardia: As per ESC 2021 guidelines, perform permanent pacing in patients with SND with symptoms clearly attributable to bradyarrhythmias. B Show 3 more As per JHRS/JCS 2021 guidelines, perform permanent pacing in patients with symptoms (such as syncope, convulsions, blacking out, dizziness, shortness of breath, and easy fatigability), or HF confirmed to be due to bradycardia, sinoatrial block, or sinus arrest associated with primary https://web.pathway.md/diseases/recqRXp3bvdVQRp0w 5/10 6/24/23, 3:06 PM Sick sinus syndrome Pathway SND, or HR insufficiency during exercise, including patients with symptoms caused by long-term treatment with drugs that cannot be discontinued. B Show 2 more As per HRS/AHA/ACC 2019 guidelines, perform permanent pacing to increase HR and improve symptoms in patients with symptoms directly attributable to SND. B Show 5 more As per ESC 2018 guidelines, perform cardiac pacing in patients with an established relationship between syncope and symptomatic bradycardia due to sick sinus syndrome. B As per HRS/AHA/ACC 2013 guidelines, perform permanent pacing in patients with SND with documented symptomatic bradycardia, including frequent sinus pauses producing symptoms. B Show 5 more Permanent pacing, shared decision-making: As per ESC 2021 guidelines, make decisions in patients eligible for pacemaker or cardiac resynchronization therapy based on the best available evidence with consideration of individual risk-benefits of each option, the patient's preferences, and goals of care, and follow an integrated care approach and use the principles of patient-centered care and shared decision- making in the consultation. B As per HRS/AHA/ACC 2019 guidelines: Engage patients with symptomatic bradycardia in a shared decision-making process for treatment decisions and base treatment decisions on the best available evidence and the patient's goals of care, preferences, and values. B Inform patients eligible for implantation of a pacemaker or with a pacemaker requiring lead revision or generator change about procedural benefits and risks, including the potential short and long-term complications and possible alternative therapy, if any, in light of their goals of care, preferences, and values. B Permanent pacing (pre-implantation assessment): assess the risk of future ventricular arrhythmias and the need for an ICD in patients requiring permanent pacing therapy. B Permanent pacing (peri-implantation care): administer preoperative antibiotic prophylaxis within 1 hour of skin incision to reduce the risk of cardiovascular implantable electronic device infection. A Show 8 more Permanent pacing, choice of leads: As per ESC 2021 guidelines: Consider placing leadless pacemakers as an alternative to transvenous pacemakers if no upper extremity venous access exists or when the risk of device pocket infection is particularly high, such as previous infection and patients on hemodialysis. C Consider placing leadless pacemakers as an alternative to standard single-lead ventricular pacing, taking into consideration life expectancy and using shared decision-making. C https://web.pathway.md/diseases/recqRXp3bvdVQRp0w 6/10 6/24/23, 3:06 PM Sick sinus syndrome Pathway As per ESC 2021 guidelines, consider using quadripolar leads as the first choice for the implantation of coronary sinus leads. C Permanent pacing, singl- vs. dual-chamber pacing: As per ESC 2021 guidelines: Program dual-chamber pacemakers to minimize unnecessary ventricular pacing in patients with SND. A Consider programming atrial anti-tachycardia pacing in patients with tachycardia-bradycardia syndrome. C As per HRS/AHA/ACC 2019 guidelines, perform atrial-based pacing over single-chamber ventricular pacing in symptomatic patients with SND. B Show 5 more Permanent pacing (septum pacing): consider performing pacing of the mid-ventricular septum in patients at high risk of perforation (such as the elderly, previous perforation, low BMI, and female patients). C Permanent pacing (cardiac resynchronization therapy): consider upgrading to cardiac resynchronization therapy in patients with a conventional pacemaker or an ICD subsequently developing symptomatic HF with LV ejection fraction 35% despite optimal medical therapy, and with a significant proportion of RV pacing. C Show 2 more Permanent pacing (remote monitoring): offer remote device management to reduce the number of in-office follow-ups in patients with pacemakers having difficulties attending in-office visits, such as due to reduced mobility or other commitments, or according to patient preference. A Show 3 more Permanent pacing (considerations for MRI): Recognize that MRI can be performed safely following the manufacturer's instructions in patients with MRI-conditional pacemaker systems. A Consider obtaining MRI in patients with non-MRI-conditional pacemaker systems if no alternative imaging mode is available and if no epicardial leads, abandoned or damaged leads, or lead adaptors/extenders are present. C Consider obtaining MRI in patients with abandoned transvenous leads if no alternative imaging modality is available. C Permanent pacing, discontinuation: As per ESC 2021 guidelines, decide on the management strategy for patients no longer requiring pacing based on an individual risk-benefit analysis in a shared decision-making process together with the patient. B As per HRS/AHA/ACC 2019 guidelines, consider discontinuing pacemaker therapy, after an evaluation of symptoms during a period of monitoring while pacing therapy is off, in patients presenting for pacemaker pulse generator replacement or for management of pacemaker- related complications if the original indication of pacing has resolved or is in question. C https://web.pathway.md/diseases/recqRXp3bvdVQRp0w 7/10 6/24/23, 3:06 PM Sick sinus syndrome Pathway 5. Perioperative care Prophylactic periopeative pacing: consider placing transcutaneous pacing pads in patients deemed at high risk for the development of intraoperative or periprocedural bradycardia because of patient characteristics or procedure type. C Show 2 more 6. Specific circumstances Patients with beta-blocker toxicity: Consider administering glucagon to increase HR and improve symptoms in patients with bradycardia associated with symptoms or hemodynamic compromise caused by -blocker overdose. C Consider administering high-dose insulin to increase HR and improve symptoms in patients with bradycardia associated with symptoms or hemodynamic compromise caused by -blocker overdose. C Patients with calcium channel blocker toxicity: As per ACC 2019 guidelines, consider administering IV calcium to increase HR and improve symptoms in patients with bradycardia associated with symptoms or hemodynamic compromise caused by CCB overdose. C Show 2 more As per AAPCC 2017 guidelines, administer IV calcium as first-line therapy in patients with symptomatic CCB overdose. Administer high-dose insulin in addition to other first-line treatments in the presence of myocardial dysfunction in patients with CCB overdose. B Show 3 more Patients with digoxin toxicity: Consider administering digoxin immune fab to increase HR and improve symptoms in patients with bradycardia associated with symptoms or hemodynamic compromise in the setting of digoxin toxicity. C Do not perform dialysis for removal of digoxin in patients with bradycardia associated with symptoms or hemodynamic compromise attributable to digoxin toxicity. D Patients with tachycardia-bradycardia syndrome, permanent pacing: As per ESC 2021 guidelines: Perform permanent pacing to correct bradyarrhythmias and enable pharmacological treatment in symptomatic patients with tachycardia-bradycardia syndrome, unless ablation of the tachyarrhythmia is preferred. B Consider programming atrial anti-tachycardia pacing in patients with tachycardia-bradycardia syndrome. C As per HRS/AHA/ACC 2019 guidelines, consider performing permanent pacing to increase HR and reduce symptoms attributable to hypoperfusion in patients with tachycardia-bradycardia https://web.pathway.md/diseases/recqRXp3bvdVQRp0w 8/10 6/24/23, 3:06 PM Sick sinus syndrome Pathway syndrome and symptoms attributable to bradycardia. C Patients with tachycardia-bradycardia syndrome (AF ablation): consider performing AF ablation as a strategy to avoid pacemaker implantation in patients with AF-related bradycardia or symptomatic pre-automaticity pauses, after AF conversion, taking into account the clinical situation. C Patients with acute myocardial infarction: consider administering atropine in patients with acute myocardial infarction with symptomatic or hemodynamically significant sinus bradycardia. C Show 2 more Patients with Lyme carditis: perform temporary rather than permanent pacing in patients with symptomatic bradycardia due to Lyme carditis not being manageable medically. B Patients with congenital heart disease: As per ESC 2021 guidelines, consider performing permanent pacing on an individual basis in patients with complex congenital heart disease and asymptomatic bradycardia (awake resting HR < 40 bpm or pauses > 3 sec). C As per ACC 2019 guidelines, perform atrial-based permanent pacing in patients with adult congenital heart disease and symptomatic SND or chronotropic incompetence. B Show 4 more Patients after cardiac surgery: perform placement of a permanent pacemaker before discharge in patients with new postoperative SND associated with persistent symptoms or hemodynamic instability not resolved after mitral valve repair/replacement, tricuspid valve surgery, aortic valve replacement, surgery for AF, or isolated coronary artery bypass surgery. B Patients after heart transplantation: As per ESC 2021 guidelines, consider performing cardiac pacing to improve quality of life in patients with chronotropic incompetence persisting for > 6 weeks after heart transplantation. C As per ACC 2019 guidelines: Consider administering aminophylline or theophylline to increase HR in post-heart transplant patients. C Do not administer atropine to treat sinus bradycardia in post-heart transplant patients without evidence of autonomic reinnervation. D Patients with obstructive sleep apnea: offer treatment directed specifically at sleep apnea (such as CPAP and weight loss) in patients with sleep-related bradycardia and documented obstructive sleep apnea. B Patients with accidental hypothermia: consider performing transcutaneous pacing in patients with hypothermia in the setting of bradycardia with hypotension disproportionate to the core temperature. C Patients with acute spinal cord injury: consider administering aminophylline or theophylline to increase HR and improve symptoms in patients with SND associated with symptoms or hemodynamic compromise in the setting of acute spinal cord injury. C https://web.pathway.md/diseases/recqRXp3bvdVQRp0w 9/10 6/24/23, 3:06 PM Sick sinus syndrome Pathway Patients with neuromuscular disorders: perform permanent pacing (if concordant with the patient's goals of care and clinical status) in patients with Duchenne muscular dystrophy, Becker muscular dystrophy, or Limb-girdle muscular dystrophy type 2 with documented symptomatic bradycardia due to any degree of SND. B References 1. Ashish R Panchal, Jason A Bartos, Jos G Caba as et al. Part 3 Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142 16_suppl_2 S366 S468. Open 2. Michael Glikson, Jens Cosedis Nielsen, Mads Brix Kronborg et al. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J. 2021 Sep 14;42 35 3427 3520. Open 3. Fred M Kusumoto, Mark H Schoenfeld, Coletta Barrett et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2019 Aug 20;140 8):e382-e482. Open 4. William J Groh, Deepak Bhakta, Gordon F Tomaselli et al. 2022 HRS expert consensus statement on evaluation and management of arrhythmic risk in neuromuscular disorders. Heart Rhythm. 2022 Oct;19 10):e61-e120. Open 5. Katsushige Ono, Yu-Ki Iwasaki, Masaharu Akao et al. JCS/JHRS 2020 Guideline on Pharmacotherapy of Cardiac Arrhythmias. J Arrhythm 2022 Oct 25;38 6 833 973. Open 6. 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Clinical Practice Guidelines by the Infectious Diseases Society of America IDSA , American Academy of Neurology AAN , and American College of Rheumatology ACR 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease. Arthritis Care Res Hoboken). 2021 Jan;73 1 1 9. Open 10. Maude St-Onge, Kurt Anseeuw, Frank Lee Cantrell et al. Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults. Crit Care Med. 2017 Mar;45 3):e306-e315. Open 11. Dow J, Giesbrecht GG, Danzl DF et al. Wilderness Medical Society Clinical Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2019 Update. Wilderness Environ Med. 2019 Dec;30 4S S47 S69. Open https://web.pathway.md/diseases/recqRXp3bvdVQRp0w 10/10