The following signs and symptoms are seen in sick sinus syndrome:

• General appearance: Patients will often times appear fatigued due to brain and muscle hypoperfusion.
• Chest and heart: Chest pain may be occasionally felt due to cardiac hypoperfusion. Difficulty in breathing may be due to generalized hypoxemia.
• Abdomen: Distention due to ascites in congestive heart failure complications.
• Extremities: Slower peripheral pulses with bradycardia.
• Neurologic: Patients will complain of dizziness, confusion and near syncope due to hypotension.

• Fatigue

  (palpitations) When to see a doctor If you have lightheadedness, dizziness, fainting, fatigue, shortness of breath or palpitations, talk to your doctor. [mayoclinic.org]

  Other: digestive disturbances, dizziness, errors in judgment, facial flushing, fatigue, oliguria. [patient.info]

  A 58-year-old woman complained of general fatigue and was diagnosed with sick sinus syndrome (SSS) by ambulatory electrocardiogram, which demonstrated sinus arrest at midnight and paroxysmal atrial fibrillation (AF) at nighttime. [ncbi.nlm.nih.gov]

  dizziness, and alternating periods of bradycardia and atrial tachycardia, which is caused by sinoatrial node dysfunction A constellation of signs and symptoms which may include syncope, fatigue, dizziness, and alternating periods of bradycardia and [icd9data.com]

• Congestive Heart Failure

  Following pacemaker implantation, the pressure gradient has been reduced and congestive heart failure controlled for the past 3 years. [ncbi.nlm.nih.gov]

• Surgical Procedure

  […] that involves temporarily or permanently placing a pacemaker within the chest wall The following article link will help you understand pacemaker implantation surgical procedure: https://www.dovemed.com/common-procedures/procedures-surgical/pacemaker-implantation [dovemed.com]

  In more advanced cases, surgical procedures on the eyes, ears, or even the heart, may be necessary. Early diagnosis and treatment are important to lower the risks of permanent hearing or vision loss. [vasculitisfoundation.org]

  This very common childhood infection sometimes requires a surgical procedure called myringotomy and tube insertion. Otitis interna, or labyrinthitis, involves the inner ear. The inner ear includes sensory organs for balance and hearing. [en.wikipedia.org]

  This small, battery-powered electronic device is implanted under the skin near your collarbone during a minor surgical procedure. The type of pacemaker you need depends on your irregular heart rhythm. [baptisthealth.com]

• Weight Loss

  Continuous positive airway pressure treatment at a pressure of 12 cm H2O was started, and weight loss was recommended. Figure 1. Upper panel (A) indicates the heart rate trend throughout the tracing (mean, 51 bpm; range, 31-86 bpm). [revespcardiol.org]

  loss, tiredness and weakness Some tumours may not cause any symptoms and are discovered by chance. [nhs.uk]

  Past medical history should ask about risk factors for tinnitus, including exposure to loud noise, sudden pressure change (from diving or air travel), history of ear or CNS infections or trauma, radiation therapy to the head, and recent major weight loss [merckmanuals.com]

• Collapse

  […] complications of a pacemaker implant include: myocardial perforation (accidental hole made in the heart during surgery) infection from the implant (bacteria brought in during surgery causes infection) venous thrombosis (blood clot within the body’s veins) collapsed [healthline.com]

  An electrophysiologic study was performed and was notable for the induction of self-limited P VT with hemodynamic collapse (induction protocol: S1 400/S2 200 ms, pacing at the right ventricular apex). [revportcardiol.org]

• Flatulence

  […] of antibiotic combination of approach to reduce the level acquired through special instrument and cures all the digestive track of our human body in the form of oral or injectable drug” Prilosec earns its manufacture of a warming world and those with flatulence [sdsweb.co]

• Tachycardia

  Depending on the extent of bradycardia or tachycardia, the condition may be asymptomatic or present with symptoms such as palpitations or dyspnea. [amboss.com]

  […] there can be flushing of face [4] Retrosternal pressure [4] Due to pounding of the heart associated with tachycardia, tachy-brady syndrome [4] [explainmedicine.com]

  Types of tachycardias include atrial fibrillation, atrial flutter/tachycardia, and supraventricular tachycardia bradycardia-tachycardia, which causes alternating slow and fast heart rhythms A problem with a part of the heart called the sinus node causes [health.harvard.edu]

  In some cases, the heartbeat rapidly switches from being too fast to being too slow, a condition known as tachycardia-bradycardia syndrome. [icdlist.com]

  (fast heart rate) such as atrial tachycardia (PAT) and atrial fibrillation. [en.wikipedia.org]

• Heart Disease

  Sustained bradycardia is infrequent in prenatal life and associated with maternal collagen vascular diseases, structural heart diseases or long QT syndrome. [ncbi.nlm.nih.gov]

  SSS occurs most often in the elderly associated with underlying heart disease or previous cardiac surgery, but can also occur in the fetus, infant, or child without heart disease or other contributing factors. [malacards.org]

  Coronary heart disease, high blood pressure, and aortic and mitral valve diseases may occur with sick sinus syndrome. However, these diseases may have nothing to do with the syndrome. Sick sinus syndrome is uncommon, but not rare. [medlineplus.gov]

  Coronary heart disease, high blood pressure, and aortic and mitral valve diseases may occur with sick sinus syndrome. However, these diseases may have nothing to do with the syndrome. Sick sinus syndrome is uncommon. [stlukes-stl.com]

• Heart Failure

  No statistically significant difference was found between the pacing modes for mortality, heart failure, stroke, chronic atrial fibrillation or quality of life. However, the risk of developing heart failure may vary with age and device. [ncbi.nlm.nih.gov]

  Incident heart failure in the ARIC study was defined as presence of an ICD code for heart failure (ICD9 428, ICD10 I50) in a hospitalization or death certificate [18]. [journals.plos.org]

• Irregular Heart Rhythm

  Disruption of the node in SSS leaves patients at risk of a dangerous irregular heart rhythm often requiring a pacemaker to be fitted to correct the heart rhythm. [bhf.org.uk]

  The type of pacemaker you need depends on your irregular heart rhythm. [baptisthealth.com]

  The pacemaker is programmed to stimulate or "pace" your heart as needed to keep it beating normally. The type of pacemaker you need depends on the type of irregular heart rhythm you have. [mayoclinic.org]

  These signs include: a slower than normal pulse rate, irregular heart rhythm or pauses by auscultation, escape rhythms from alternate intracardiac pacemaker sites on a 12-lead EKG, a heart rhythm that alternates between slow and fast rates, and low blood [washingtonhra.com]

• Slow Pulse

  The mainstay of treatment is ventricular pacing for bradyarrhythmias (slow pulse rate) for pauses of 2-3 seconds or more. [healthengine.com.au]

  Electrocardiography A slow pulse (especially an irregular one), a pulse that varies greatly without any change in the person’s activity, or a pulse that does not increase during exercise suggests sinus node dysfunction. [msdmanuals.com]

  When they do occur, symptoms may include: A fluttering or rapid heartbeat sensation, known as palpitations A slow pulse Chest pains Dizziness Fainting, or feeling faint Fatigue Lightheadedness Shortness of breath Sick Sinus Syndrome Diagnosis Symptoms [baptisthealth.com]

• Vertigo

  Benign Paroxysmal Positional Vertigo (BPPV) Benign Paroxysmal Positional Vertigo (BPPV) causes short episodes of vertigo or dizziness when moving your head in certain directions. [hearinglink.org]

  The primary treatments for Meniere disease are: diuretics, anti-vertigo, anti-nausea, and low salt diets. Surgery may be recommended if the vertigo cannot be controlled with medication. [medicinenet.com]

  When the inner ear is inflamed, vertigo is a common symptom. External links[edit] Classification D ICD-9-CM: 380.10 MeSH: D010031 External resources MedlinePlus: 001336 [en.wikipedia.org]

  In 1984 Jannetta et al. introduced the term-disabling positional vertigo due to vascular loop pressure [3]. There are no specific features of the syndrome and because of that is not a condition acceptable to all researches [2,4]. [jneuro.com]

  Histamine and betahistine in the treatment of vertigo: elucidadtion of mechanisms of action. CNS Drugs. 2001;15:853-70. [ Links ] 23. Ganança MM, Munhoz MSL, Caovilla HH, Silva MLG. Managing vertigo. Hannover: Solvay; 2006.p.112. [ Links ] 24. [scielo.br]

• Irritability

  Presentation may be with fatigue, dizziness, palpitations, and syncope or presyncope.[4] Central nervous system: dementia, irritability, lethargy, light-headedness, confusion, memory loss, nocturnal wakefulness, syncope. [patient.info]

  Avoid problematic foods and drinks Strong-tasting or harsh foods and beverages can irritate the mouth. [medicalnewstoday.com]

  Fecal transplant is used to treat gut infections and is now being studied as a treatment for obesity, urinary tract infections, irritable bowel syndrome and more. [nytimes.com]

  According to Vass,10 trigeminal nerve irritation induced by the TMJD can disturb the normal inner-ear vascular tone causing some otologic disturbances such as tinnitus. [hearingreview.com]

  The New York Times recently reported on a really interesting treatment for tinnitus, the irritating (and sometimes crazy-making) ringing in the ears that sometimes accompanies noise-related hearing loss. [scopeblog.stanford.edu]

• Slurred Speech

  Symptoms include headaches, slurred speech, and trouble focusing. Treatment includes drugs that suppress the immune system, such as steroids. What is Susac's syndrome? Susac's syndrome is a rare, autoimmune disease. [my.clevelandclinic.org]

  Other symptoms that are noted occasionally include personality changes, irritability, fleeting memory losses, generalized weakness or fatigue, muscle aches, slurred speech, and insomnia. Physical examination. [tele.med.ru]

• Forgetful

  Looking back at the wall calendar, I remembered that today is September 18, listening to the screaming alarm, my heart is full of emotion, remember nine one eight do not forget the ninety eight. [lifeprep.us]

  So for example, if we consider the ticking of a clock, we will very often not react to it and may forget that it is there unless we consciously draw our attention to it. In other words, we will get used to it or habituate. [tinnitus.org.uk]

• Drop Attacks

  Drop attacks (Tumarkin’s otholic crisis) Drop attacks, known as Tumarkin’s otolithic crisis, are when a person falls to the ground with no warning. The person remains awake and does not lose consciousness. [menieres.org.uk]

Patients may be initially examined physically when they present in the emergency room, they would most likely reveal irregular pulse rate and low blood pressure. Auscultation findings of slow rhythm and skip beats may be suggestive of a dysfunctional node. The succeeding tests for diagnosis may be implored in patients with high suspicion of sick sinus syndrome:

• Electrocardiogram (ECG): Sick sinus syndrome may convey a characteristic pattern on ECG. Findings of bradyarrhythmias with heart rates less than 46-51 beats per minute may suggestive of a nodal pathology [8]. 
• Holter monitor: This is a portable device that monitors the heart rhythm in a 24-48 hours period. It allows the cardiologist to detect heart rhythm abnormalities in an extended period of time. Sinus pauses of more than 3 seconds except in rare conditions like seizure disorders and sleep apnea syndrome is suggestive of a nodal pause or arrest [9].
• Event recorder: This is also a portable device that may monitor the heart’s electrical activity at the time of an event with just a push of a button.
• Implantable loop recorder: This small implantable device may is placed under the skin of the chest to monitor cardiac electrical activities from months to years. Rhythms may be recorded automatically when an event occurs or with a press of a button every time the patients feel some discomforts. 

• Prolonged PR Interval

  This is seen as a PR interval greater than 200 ms in length on the surface ECG. 15. Clinical Findings:        History: Generally asymptomatic at rest Markedly prolonged PR interval may reduce exercise tolerance in some patients. [slideshare.net]

  The effect of this PR interval prolongation on AV dyssynchrony is demonstrated in this ECG image. AV dyssynchrony resulting from severe PR interval prolongation in the setting of sinus rhythm. [emedicine.medscape.com]

• Sinus Arrest

  So even though sinus pause and sinus arrest is used many times interchangeably, it should be avoided. What are the electrophysiological mechanisms of sinus pause ? Simple sinus bradycardia. The commonest mechanism is the increased vagal tone. [drsvenkatesan.com]

  The diagnosis of SSS was based on electrocardiographic evidence of markedly prolonged sinus arrests associated with syncope attacks while in hospital. [ncbi.nlm.nih.gov]

  Sinoatrial node depolarization is irregular or fails, resulting in bradycardia or sinus arrest. In the presence of sinus arrest or extreme sinus bradycardia, a junctional escape rhythm may develop. [accessanesthesiology.mhmedical.com]

  Sinus Arrhythmia — associated with sinus node dysfunction in the elderly in the absence of respiratory pattern association. Sinoatrial Exit Block. Sinus Arrest — pause > 3 seconds. Atrial fibrillation with slow ventricular response. [lifeinthefastlane.com]

• Sinus Arrhythmia

  The most common SSS arrhythmias are sinus bradycardia and non-respiratory sinus arrhythmia. Depending on the extent of bradycardia or tachycardia, the condition may be asymptomatic or present with symptoms such as palpitations or dyspnea. [amboss.com]

  Related Topics Sinus Bradycardia Sinus Arrhythmia Sinoatrial Exit Block References Da Costa D, Brady WJ, Edhouse J. Bradycardias and atrioventricular conduction block. [lifeinthefastlane.com]

  Arythmie sinusale — Arrhythmia, Sinoatrial, Arrhythmia, Sinus, Sinoatrial Arrhythmia, Sinus Arrhythmia - Bloc cardiaque, Dissociation atrioventriculaire, Dissociation atrio-ventriculaire, Dissociation auriculoventriculaire, Dissociation auriculo-ventriculaire [proz.com]

  Sign in Published on Feb 12, 2015 A summary of sinus node dysfunction, including sinus arrhythmia, SA exit block, sinus pauses, sinus arrest, sinus bradycardia, chronotropic incompetence, sick sinus syndrome, and the tachy-brady syndrome. [youtube.com]

The main goal in the treatment of sick sinus syndrome focuses on the control of the patient’s discomfort. Nodal dysfunction may present mildly or asymptomatic, and may no longer require treatment. Patients on current hypertensive medications like beta-blockers and calcium channel blockers may need some revisions to control the symptoms.

Some patients with sick sinus syndrome may require a permanent pacing device called pacemakers which are implanted beneath the chest wall skin. Anti-arrhythmics may be given to patients with pacemaker whom rhythm remain abnormal. The regular intake of warfarin in face of arrhythmia in nodal dysfunction can prevent strokes in the future.

AV node ablation using radiofrequency probes to control irregularly fast rhythms can subdue tachyarrhythmia in sick sinus syndrome. However, nodal ablation may have a recurrence of abnormal pacing and may revert to atrial fibrillation as long term complication in a number of cases [10].

Sick sinus syndrome may rarely lead to sudden cardiac death [4]. Patients usually succumbs with their underlying cardiac disease rather than with the nodal dysfunction. The use of a cardiac pacemaker is primarily to alleviate symptoms and does not affect the overall mortality rating of the cardiac patients [5]. Patient with nodal dysfunction but with normal systemic ventricular function carry a very good prognosis. Among the sick sinus syndrome subtypes, the bradycardia-tachycardia syndrome has a guarded prognosis compared to the others.

Complications

The following sick sinus syndrome complications can lead to significant morbidity and mortality among cardiac patients:

• Near syncope or syncope
• Falls
• Sudden cardiac death
• Cerebrovascular disease (stroke)
• Congestive heart hailure [6]
• Intolerance to slight exercises
• Cardiac dysrhythmias
• Atrial flutter and fibrillation [7]

The sinus node is the natural pacemaker of the heart that produces the electric impulses that initiates each heartbeat. These impulses traverse from the atria to the ventricles and contract the cardiac muscles to force out the blood. A sick sinus may insinuate a slow rhythm (bradycardia) or a very fast rhythm (tachycardia) that causes characteristic symptoms of the disease.

The following are the different types of sick sinus syndrome and their probable causes:

• Sinus arrest: This is due to the halting of the sinus activity.
• Sinoatrial block: Electrical impulses are described to move slowly through the sinus node causing a slow heart rate.
• Bradycardia-Tachycardia syndrome: There is an alternate fast and slow pace rhythms with a long pause between heartbeats.

There are no available data on the exact incidence of sick sinus syndrome worldwide. The incidence of sick sinus syndrome is 1 out of 600 cardiac patients beyond 65 years of age [2]. Because sick sinus syndrome correlates well with old age, this syndrome is more prevalent in countries with high life expectancy. The age related occurrence of sick sinus syndrome has an average of 68 years old although it may occur in all ages [3]. The prevalence of sick sinus syndrome among the younger age group is usually associated with an underlying heart condition.

The basic pathophysiology of sick sinus syndrome falls on the propagation of electrical impulses. Sometimes, the conduction path at the atrium is obscured by injury causing a delay in the conduction to the heart muscles. The ventricular contraction rate is consequently slowed down and may present with long pauses in between impulses, rest or stressful activities. Mild cases of sick sinus syndrome may be asymptomatic. Presentation of signs and symptoms occurs with concomitant organ hypoperfusion or irregular pulses.

By keeping one’s heart healthy by eating a balanced diet and by doing regular exercises, one may prevent the occurrence of sick sinus syndrome and other heart diseases. One must avoid taking unprescribed medications to avoid any adverse reactions that can cause arrhythmias in the future. These are good advices but majority of sick sinus cases are not preventable.

Sick sinus syndrome is a clinical disease characterized by the persistent dysfunction of the sinus node in the heart. Sick sinus syndrome is sometimes referred to as sinus node disease or sinus node dysfunction in medical literatures. The sinus node is defined as the specialized group of cells located in the right upper chamber of the cardiac musculature.

This node generates electrical impulses throughout the heart in a steady pace of regular electrical discharges. In sick sinus syndrome, these electrical impulses are abnormally paced whether too fast or too slow. Sick sinus syndrome is a relatively rare disease that occurs more often in older people that may eventually require a pacemaker to restore the heart’s normal rhythm [1].

Definition

Sick sinus syndrome refers to the persistent dysfunction of AV node in the heart causing abnormal heart rhythms.

Cause

Sinus arrest, Sino-atrial block and tachy-brady arrhythmias are possible causes of the condition.

Symptoms

Chest pain, confusion, fatigue, dypnea and abnormal pulses may occur.

Diagnosis

Clinical examination, electrocardiogram (ECG) and Holter monitor may be needed to diagnose sick sinus syndrome.

Treatment and follow-up

Anti-arrhythmic drugs, anticoagulants, pacemaker insertion and AV node ablation using radio frequency are treatment options.

1. Semelka M, Gera J, Usman S. Sick sinus syndrome: a review. Am Fam Physician. 2013; 87(10):691-6 (ISSN: 1532-0650)
2. Rodriguez RD, Schocken DD. Update on sick sinus syndrome, a cardiac disorder of aging. Geriatrics. Jan 1990; 45(1):26-30, 33-6.
3. Adán V, Crown LA. Diagnosis and treatment of sick sinus syndrome. Am Fam Physician. Apr 15 2003; 67(8):1725-32.
4. Lamas GA, Lee KL, Sweeney MO, Silverman R, Leon A, Yee R, et al. Ventricular pacing or dual-chamber pacing for sinus-node dysfunction. N Engl J Med. Jun 13 2002; 346(24):1854-62.
5. Alt E, Völker R, Wirtzfeld A, Ulm K. Survival and follow-up after pacemaker implantation: a comparison of patients with sick sinus syndrome, complete heart block, and atrial fibrillation. Pacing Clin Electrophysiol. Nov 1985; 8(6):849-55.
6. Riahi S, Nielsen JC, Hjortshøj S, Thomsen PE, Højberg S. 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. 2012; 14(10):1475-82 (ISSN: 1532-2092)
7. Lin YS, Guo GB, Chen YL, Tsai TH, Pan KL, Liu WH. Atrial size independently correlates with the development of paroxysmal atrial fibrillation in patients with sick sinus syndrome. Chang Gung Med J. 2010; 33(6):659-67 (ISSN: 2309-835X)
8. Spodick DH. Normal sinus heart rate: sinus tachycardia and sinus bradycardia redefined. Am Heart J. Oct 1992; 124(4):1119-21.
9. Hilgard J, Ezri MD, Denes P. Significance of ventricular pauses of three seconds or more detected on twenty-four-hour Holter recordings. Am J Cardiol. Apr 1 1985;55(8):1005-8
10. Masuda M, Inoue K, Iwakura K, Okamura A, Koyama Y. Preprocedural ventricular rate predicts subsequent sick sinus syndrome after ablation for long-standing persistent atrial fibrillation. Pacing Clin Electrophysiol. 2012; 35(9):1074-80 (ISSN: 1540-8159)