https://www.uptodate.com/contents/sinus-tachycardia-evaluation-and-management/print 12/22 7/6/23, 11:22 AM Sinus tachycardia: Evaluation and management - UpToDate due to the impact of the tachycardia in the presence of underlying heart disease. (See 'Clinical presentation' above.) In contrast, patients with POTS or inappropriate sinus tachycardia are generally symptomatic. (See 'Postural orthostatic tachycardia syndrome' above and 'Inappropriate sinus tachycardia' above.) Diagnosis Sinus tachycardia is generally confirmed by ECG after a rapid pulse is identified on physical examination, with the diagnosis usually being easy to establish from the surface ECG. Since the tachycardia arises from the SA node, the P waves should have a normal or near-normal appearance on ECG and should occur in a regular fashion ( waveform 2). (See 'Confirm sinus tachycardia' above.) Management For physiologic sinus tachycardia In most settings, sinus tachycardia will improve or resolve following treatment directed at the underlying etiology. Patients with sinus tachycardia who have hypotension or signs of shock related to suspected volume depletion, signs of sepsis, or acute clinical deterioration related to another suspected medical condition (eg, hypoxia, myocardial ischemia, heart failure, etc) require admission for evaluation and treatment. (See 'Management' above.) For acute coronary syndrome Because persistent tachycardia in a patient with acute coronary syndrome can result in larger infarcts and a more marked impairment in left ventricular function, treatment of sinus tachycardia with beta blockers is appropriate in most patients. (See 'Management in patients with acute coronary syndrome' above and "Acute myocardial infarction: Role of beta blocker therapy".) For inappropriate sinus tachycardia Treatment of symptomatic inappropriate sinus tachycardia is challenging, often with suboptimal results. Before embarking on treatment, exclusion of secondary causes of sinus tachycardia is imperative. For patients with symptomatic inappropriate sinus tachycardia, we suggest a trial of beta blockade as the initial medical therapy (Grade 2C). We typically start long-acting metoprolol 25 to 50 mg daily, with upward titration for adequate heart rate and symptom control. Results are often disappointing. (See 'Beta blockers' above.) For patients with persistently symptomatic inappropriate sinus tachycardia, we suggest using ivabradine (5 mg to 7.5 mg twice daily) (Grade 2C). If symptomatic sinus tachycardia persists or the response is suboptimal, we will then add a beta blocker. Ivabradine is not available in all countries and its use for inappropriate sinus https://www.uptodate.com/contents/sinus-tachycardia-evaluation-and-management/print 13/22 7/6/23, 11:22 AM Sinus tachycardia: Evaluation and management - UpToDate tachycardia would be considered an off-label use in the United States. (See 'Ivabradine' above.) For patients with persistent symptomatic inappropriate sinus tachycardia despite optimal pharmacologic therapy, radiofrequency catheter ablation may be attempted. Postural orthostatic tachycardia syndrome must be excluded first, since ablation may worsen symptoms in these patients. (See 'Catheter ablation' above.) ACKNOWLEDGMENT The UpToDate editorial staff acknowledges Leonard Ganz, MD and Brian Olshansky, MD, who contributed to an earlier version of this topic review. Use of UpToDate is subject to the Terms of Use. REFERENCES 1. Yusuf S, Camm AJ. The sinus tachycardias. Nat Clin Pract Cardiovasc Med 2005; 2:44. 2. Palatini P. 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Postural tachycardia syndrome (POTS). J Cardiovasc Electrophysiol 2009; 20:352. 9. Bauernfeind RA, Amat-Y-Leon F, Dhingra RC, et al. Chronic nonparoxysmal sinus tachycardia in otherwise healthy persons. Ann Intern Med 1979; 91:702. https://www.uptodate.com/contents/sinus-tachycardia-evaluation-and-management/print 14/22 7/6/23, 11:23 AM Sinus tachycardia: Evaluation and management - UpToDate 10. Morillo CA, Klein GJ, Thakur RK, et al. Mechanism of 'inappropriate' sinus tachycardia. Role of sympathovagal balance. Circulation 1994; 90:873. 11. Krahn AD, Yee R, Klein GJ, Morillo C. Inappropriate sinus tachycardia: evaluation and therapy. J Cardiovasc Electrophysiol 1995; 6:1124. 12. Olshansky B, Sullivan RM. Inappropriate sinus tachycardia. J Am Coll Cardiol 2013; 61:793. 13. Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2016; 133:e506. 14. Lee RJ, Shinbane JS. Inappropriate sinus tachycardia. Diagnosis and treatment. Cardiol Clin 1997; 15:599. 15. Shabtaie SA, Witt CM, Asirvatham SJ. Natural history and clinical outcomes of inappropriate sinus tachycardia. J Cardiovasc Electrophysiol 2020; 31:137. 16. Rubenstein JC, Freher M, Kadish A, Goldberger JJ. Diurnal heart rate patterns in inappropriate sinus tachycardia. Pacing Clin Electrophysiol 2010; 33:911. 17. Olshansky B. What's So Inappropriate About Sinus Tachycardia? J Cardiovasc Electrophysiol 2008; 19:977. 18. Glatter KA, Cheng J, Dorostkar P, et al. Electrophysiologic effects of adenosine in patients with supraventricular tachycardia. Circulation 1999; 99:1034. 19. Lee RJ, Kalman JM, Fitzpatrick AP, et al. Radiofrequency catheter modification of the sinus node for "inappropriate" sinus tachycardia. Circulation 1995; 92:2919. 20. Romeo E, Grimaldi N, Sarubbi B, et al. A pediatric case of cardiomyopathy induced by inappropriate sinus tachycardia: efficacy of ivabradine. Pediatr Cardiol 2011; 32:842. 21. Winum PF, Cayla G, Rubini M, et al. A case of cardiomyopathy induced by inappropriate sinus tachycardia and cured by ivabradine. Pacing Clin Electrophysiol 2009; 32:942. 22. Coss SF, Steinberg JS. Supraventricular tachyarrhythmias involving the sinus node: clinical and electrophysiologic characteristics. Prog Cardiovasc Dis 1998; 41:51. 23. DeSanctis RW, Block P, Hutter AM Jr. Tachyarrhythmias in myocardial infarction. Circulation 1972; 45:681. 24. Crimm A, Severance HW Jr, Coffey K, et al. Prognostic significance of isolated sinus tachycardia during first three days of acute myocardial infarction. Am J Med 1984; 76:983. 25. Severance HW Jr, Morris KG, Wagner GS. Criteria for early discharge after acute myocardial infarction: validation in a community hospital. Arch Intern Med 1982; 142:39. https://www.uptodate.com/contents/sinus-tachycardia-evaluation-and-management/print 15/22 7/6/23, 11:23 AM Sinus tachycardia: Evaluation and management - UpToDate 26. McNeer JF, Wallace AG, Wagner GS, et al. The course of acute myocardial infarction. Feasibility of early discharge of the uncomplicated patient. Circulation 1975; 51:410. 27. Becker RC, Burns M, Gore JM, et al. Early assessment and in-hospital management of patients with acute myocardial infarction at increased risk for adverse outcomes: a nationwide perspective of current clinical practice. The National Registry of Myocardial Infarction (NRMI-2) Participants. Am Heart J 1998; 135:786. 28. Brugada J, Katritsis DG, Arbelo E, et al. 2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J 2020; 41:655. 29. Femen a F, Baranchuk A, Morillo CA. Inappropriate sinus tachycardia: current therapeutic options. Cardiol Rev 2012; 20:8. 30. DiFrancesco D. Funny channels in the control of cardiac rhythm and mode of action of selective blockers. Pharmacol Res 2006; 53:399. 31. DiFrancesco D, Noble D. The funny current has a major pacemaking role in the sinus node. Heart Rhythm 2012; 9:299. 32. Koruth JS, Lala A, Pinney S, et al. The Clinical Use of Ivabradine. J Am Coll Cardiol 2017; 70:1777. 33. DiFrancesco D, Camm JA. Heart rate lowering by specific and selective I(f) current inhibition with ivabradine: a new therapeutic perspective in cardiovascular disease. Drugs 2004; 64:1757. 34. Tendera M, Talajic M, Robertson M, et al. Safety of ivabradine in patients with coronary artery disease and left ventricular systolic dysfunction (from the BEAUTIFUL Holter Substudy). Am J Cardiol 2011; 107:805. 35. Cal L, Rebecchi M, Sette A, et al. Efficacy of ivabradine administration in patients affected by inappropriate sinus tachycardia. Heart Rhythm 2010; 7:1318. 36. Cappato R, Castelvecchio S, Ricci C, et al. Clinical efficacy of ivabradine in patients with inappropriate sinus tachycardia: a prospective, randomized, placebo-controlled, double- blind, crossover evaluation. J Am Coll Cardiol 2012; 60:1323. 37. Ptaszynski P, Kaczmarek K, Ruta J, et al. Metoprolol succinate vs. ivabradine in the treatment of inappropriate sinus tachycardia in patients unresponsive to previous pharmacological therapy. Europace 2013; 15:116. 38. Benezet-Mazuecos J, Rubio JM, Farr J, et al. Long-term outcomes of ivabradine in inappropriate sinus tachycardia patients: appropriate efficacy or inappropriate patients. https://www.uptodate.com/contents/sinus-tachycardia-evaluation-and-management/print 16/22 7/6/23, 11:23 AM Sinus tachycardia: Evaluation and management - UpToDate Pacing Clin Electrophysiol 2013; 36:830. 39. Mathew ST, Po SS, Thadani U. Inappropriate sinus tachycardia-symptom and heart rate reduction with ivabradine: A pooled analysis of prospective studies. Heart Rhythm 2018; 15:240. 40. Rodr guez-Ma ero M, Kreidieh B, Al Rifai M, et al. Ablation of Inappropriate Sinus Tachycardia: A Systematic Review of the Literature. JACC Clin Electrophysiol 2017; 3:253. 41. Schweikert RA, Saliba WI, Tomassoni G, et al. Percutaneous pericardial instrumentation for endo-epicardial mapping of previously failed ablations. Circulation 2003; 108:1329. 42. Koplan BA, Parkash R, Couper G, Stevenson WG. Combined epicardial-endocardial approach to ablation of inappropriate sinus tachycardia. J Cardiovasc Electrophysiol 2004; 15:237. 43. Scheinman MM, Huang S. The 1998 NASPE prospective catheter ablation registry. Pacing Clin Electrophysiol 2000; 23:1020. 44. Shen WK, Low PA, Jahangir A, et al. Is sinus node modification appropriate for inappropriate sinus tachycardia with features of postural orthostatic tachycardia syndrome? Pacing Clin Electrophysiol 2001; 24:217. Topic 1074 Version 40.0 https://www.uptodate.com/contents/sinus-tachycardia-evaluation-and-management/print 17/22 7/6/23, 11:23 AM Sinus tachycardia: Evaluation and management - UpToDate GRAPHICS ECG of sinus rhythm to Normal electrocardiogram (ECG) Normal sinus rhythm at a rate of 71 beats/minute, a P wave axis of 45 , and a PR interval of 0.15 seconds. ECG: electrocardiogram. Courtesy of Morton Arnsdorf, MD. Graphic 58149 Version 5.0 https://www.uptodate.com/contents/sinus-tachycardia-evaluation-and-management/print 18/22 7/6/23, 11:23 AM Sinus tachycardia: Evaluation and management - UpToDate Electrocardiogram (ECG) showing sinus tachycardia at a rate of 150 beats/min Note the difficulty in separating the P waves from the T waves in the standard leads. The P waves are most evident in lead V1 (arrow) where the terminal negativity suggests left atrial enlargement. Courtesy of Morton Arnsdorf, MD. Graphic 78938 Version 3.0 https://www.uptodate.com/contents/sinus-tachycardia-evaluation-and-management/print 19/22 7/6/23, 11:23 AM Sinus tachycardia: Evaluation and management - UpToDate Normal heart rates in adults based on age and sex HR (beats per minute) Age All Male Female (years) N Mean 1%-99% N Mean 1%-99% N Mean 1%-99% 20-29 6086 67 43-98 3127 64 42-99 2959 69 46-99 30-39 9569 69 46-100 4605 67 44-99 4964 70 48-100 40-49 15,392 69 46-101 7104 68 45-101 8288 70 48-102 50-59 18,578 68 46-102 9936 68 45-102 8642 69 47-102 60-69 16,585 67 44-102 9457 65 42-102 7128 68 46-101 70-79 8432 65 43-101 4509 64 42-102 3923 67 44-101 80-89 2259 65 44-101 1001 63 41-98 1258 67 46-102 90-99 119 70 43-146 58 64 43-95 81 72 44-147 Normal heart rate values (with range from 1st to 99th percentile) for heart rate (beats/minute) in 77,276 healthy adults according to age and gender. %: percent; HR: heart rate. Data from: Mason JW, Ramseth DJ, Chanter DO, et al. Electrocardiographic reference ranges derived from 79,743 ambulatory subjects. J Electrocardiol 2007; 40:228. Graphic 77746 Version 4.0 https://www.uptodate.com/contents/sinus-tachycardia-evaluation-and-management/print 20/22 7/6/23, 11:23 AM Sinus tachycardia: Evaluation and management - UpToDate Atrial flutter at a rate of 250 beats/minute with 2:1 AV conduction in the presence of left bundle branch block Although every other flutter wave can be seen at the end of the T wave in the first part of the tracing (arrows), a sinus mechanism cannot be excluded. The flutter waves become clearly apparent after carotid sinus massage is applied to slow conduction through the AV node, thereby increasing the degree of AV block. AV: atrioventricular Courtesy of Morton Arnsdorf, MD. Graphic 76876 Version 3.0 Normal rhythm strip Normal rhythm strip in lead II. The PR interval is 0.15 sec and the QRS duration is 0.08 sec. Both the P and T waves are upright. Courtesy of Morton F Arnsdorf, MD. Graphic 59022 Version 3.0 https://www.uptodate.com/contents/sinus-tachycardia-evaluation-and-management/print 21/22 7/6/23, 11:23 AM Sinus tachycardia: Evaluation and management - UpToDate Contributor Disclosures Munther K Homoud, MD Speaker's Bureau: Abbott [Live heart dissection]. All of the relevant financial relationships listed have been mitigated. Jonathan Piccini, MD, MHS, FACC, FAHA, FHRS Grant/Research/Clinical Trial Support: Abbott [Atrial fibrillation, catheter ablation]; AHA [Atrial fibrillation, cardiovascular disease]; Bayer [Atrial fibrillation]; Boston Scientific [Cardiac mapping, pacemaker/ICD, atrial fibrillation care]; iRhythm [Atrial fibrillation]; NIA [Atrial fibrillation]; Philips [Lead management]. Consultant/Advisory Boards: Abbott [Atrial fibrillation, catheter ablation]; Abbvie [Atrial fibrillation]; Bayer [Atrial fibrillation]; Boston Scientific [Cardiac mapping, atrial fibrillation, pacemaker/ICD]; ElectroPhysiology Frontiers [Atrial fibrillation, catheter ablation]; Element Science [DSMB]; Medtronic [Atrial fibrillation, pacemaker/ICDs]; Milestone [Supraventricular tachycardia]; Pacira [Atrial fibrillation]; Philips [Lead extraction]; ReCor [Cardiac arrhythmias]; Sanofi [Atrial fibrillation]. All of the relevant financial relationships listed have been mitigated. Susan B Yeon, MD, JD, FACC No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/sinus-tachycardia-evaluation-and-management/print 22/22