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Sinus Arrest

Sinus arrest, a term used interchangeably with sinoatrial arrest, is a disorder that involves failure of the sinoatrial node to discharge an electrical impulse for 2 seconds or more. It is associated with conditions such as sinus node dysfunction, certain drugs, myocardial infarction, and electrolyte imbalances (hyperkalemia). It may or may not be symptomatic.


Presentation

Sinus arrest primarily affects older patients [1]. It may arise either as a manifestation of sinus node dysfunction, as a side effect from certain drugs used to treat cardiovascular diseases (eg. digitalis), as a complication of myocardial ischemia or sleep apnea, and alongside a fibrotic sinoatrial node condition [2] [3].

Depending on whether the arrest lasts for 2 seconds or for a longer period of time, sinus arrest causes symptoms ranging from mild/unnoticed to severe and life-threatening. Patients diagnosed with the condition usually belong to the senior age group and exhibit various comorbidities. The most common manifestations associated with sinus arrest include syncope, light-headedness, loss of orientation, weakness, angina, and heart failure [4] [5] [6]. Loss of consciousness experienced by a patient due to sinus arrest is known as Adam-Stokes attack. Oliguria may also complicate the clinical picture.

Sinus arrest during periictal period has been observed by a study to frequently arise in patients with inadequately controlled epilepsy [7]. In a typical sinus arrest case, should the electrical activity be paused for too long, different cellular groups will undertake the pacemaking responsibility until the sinoatrial node recovers. If that does not happen, sinus arrest can lead to hypoxia, multiple organ system failure, and cardiac arrest.

Epilepsy
  • Some forms of focal epilepsy, including temporal lobe epilepsy, are rarely associated with ictal bradycardia and sinus node arrest. We report a case of a previously healthy man presenting with syncope in whom telemetry revealed sinus arrest.[ncbi.nlm.nih.gov]
  • The authors report three episodes of severe bradycardia and sinus arrest that occurred in a patient undergoing anterior temporal lobectomy and amygdalo-hippocampectomy for the treatment of epilepsy.[ncbi.nlm.nih.gov]
  • Sinus arrest during periictal period has been observed by a study to frequently arise in patients with inadequately controlled epilepsy.[symptoma.com]
  • Since disturbed autonomic nervous system may be important in the development of cardiac arrhythmias at all ages, levetiracetam-type drugs may have novel therapeutic potential outside the treatment of epilepsy.[ahajournals.org]
Hypoxemia
  • Transient bradycardia in the critical care setting is frequently caused by hypoxemia or oropharyngeal manipulation.[ncbi.nlm.nih.gov]
Hypoventilation
  • We present a case of a 52-year-old man whose only features of astrocytoma consisted of episodes of apnea and sinus arrest followed by prolonged alveolar hypoventilation. These abnormalities resolved after resection of the tumor.[ncbi.nlm.nih.gov]
Hiccup
  • We describe asymptomatic sinus arrest and post-hiccup cough syncope in a patient with medullary infarction. A 78-year-old woman developed arrhythmia, hiccup, and cough syncope attacks. Neurological examination was not remarkable.[ncbi.nlm.nih.gov]
Diarrhea
  • Among the common adverse effects associated with sertraline are nausea, insomnia, diarrhea, somnolence, and dizziness. Cardiac arrest had not been reported in the literature, although tachycardia was frequently seen.[ncbi.nlm.nih.gov]
Heart Disease
  • Vasovagal syncope following exercise in the absence of structural heart disease is uncommonly reported.[ncbi.nlm.nih.gov]
  • As he was absolutely asymptomatic and free from any structural heart disease, he underwent a follow-up with repeated Holter monitorings for one year.[ncbi.nlm.nih.gov]
Slow Pulse
  • Symptoms of SSS include: fainting or fainting sensations fatigue dizziness palpitations (abnormal heart beats) very slow pulse (bradycardia) difficulty breathing chest pain mental confusion memory problems disrupted sleep It’s important to see your doctor[healthline.com]
Skipped Beats
  • Patients who have sinus pauses may complain of missed or skipped beats, flutters, palpitations, hard beats or may feel faint, dizzy or lightheaded or experience a syncopal episode (passing out). Frequent pauses would heighten these symptoms.[equimedcorp.com]
Fracture
  • Two cases are reported in which the treatment of pan-facial fractures via a bi-temporal flap approach was complicated by cessation of activity of the sinuatrial node (sinus arrest).[ncbi.nlm.nih.gov]
Muscle Cramp
  • This is one of the reasons that you develop muscle cramps during exercise. Blood salts are quick to recover as you rehydrate, unlike the salts within your muscles.[forum.cyclingnews.com]
Aggressive Behavior
  • However, because of the side-effects (hyperreactivity, aggressive behavior, and loss of appetite) the drug was eventually discontinued. As the symptoms were severe, implantation of permanent pacemaker was warranted.[ahajournals.org]
Insomnia
  • Among the common adverse effects associated with sertraline are nausea, insomnia, diarrhea, somnolence, and dizziness. Cardiac arrest had not been reported in the literature, although tachycardia was frequently seen.[ncbi.nlm.nih.gov]
  • The most common side effects of risperidone are anxiety, headaches, insomnia, and agitation, which frequently appear with high doses.[ncbi.nlm.nih.gov]
Catatonia
  • We report a case of neuroleptic malignant syndrome where the catatonia clearly followed the administration of neuroleptics and where the neurovegetative disturbance was remarkably severe, including episodes of tracheal spasm, apnoea and episodes of bradycardia[ncbi.nlm.nih.gov]
Neuralgia
  • A 64-year-old woman presented with bradycardia from sinus pauses during exacerbations of postherpetic trigeminal distribution neuralgia. She had underlying systemic lupus erythematosus.[ncbi.nlm.nih.gov]
Oliguria
  • Oliguria may also complicate the clinical picture. Sinus arrest during periictal period has been observed by a study to frequently arise in patients with inadequately controlled epilepsy.[symptoma.com]

Workup

Sinus arrest is detected via a 12-lead electrocardiogram. Senior individuals who present with symptoms possibly originating from the cardiovascular system, such as angina, loss of consciousness, and fatigue, should always undergo an electrocardiographic evaluation.

A typical sinus arrest electrocardiogram (ECG) will reveal an absence of P waves, with a duration ≥ 2 seconds. Of note, the length of the pause cannot be expressed as a multiple of the basic sinus cycle length. Occasionally and when the P waves are absent for a relatively long time, escape beats appear, as other groups of myocardial cells undertake the pacemaking process for a brief period of time. The R-R interval before and after sinus arrest is stable.

Given that sinus arrest occurs as a result of sinus node dysfunction, myocardial ischemia, certain drugs, and other causes, these need to be investigated as well. Laboratory tests can illustrate a potential hyperkalemia, the ECG will also diagnose ongoing ischemic alterations of the myocardium, and ambulatory or long-term ECG monitoring can also be employed in order to investigate the presence of an underlying pathology and confirm where the symptoms originate from [8].

Pericardial Effusion
  • Echocardiographic examination showed normal left ventricular systolic function with ejection fraction 60% and mild pericardial effusion.[ommegaonline.org]

Treatment

  • In this case report, a patient was presented who had adverse reactions such as nausea, dizziness, insomnia under citalopram treatment, and after his drug was changed to sertraline, developed sinus arrest on the fourth day of treatment.[ncbi.nlm.nih.gov]
  • Nasal continuous positive airway pressure (nCPAP) now is widely used as the treatment of SA, but little data are available on the effect of nCPAP on heart block in patients with SA.[ncbi.nlm.nih.gov]
  • The patient responded well to treatment with no adverse outcomes.[ncbi.nlm.nih.gov]
  • The arrhythmias were temporally related to cimetidine administration, disappeared after dechallenge, and did not recur during ranitidine treatment. This is the first reported case of sinus arrest associated with continuous-infusion cimetidine.[ncbi.nlm.nih.gov]
  • This case suggests that close monitoring is mandatory even during therapeutic treatment with risperidone.[ncbi.nlm.nih.gov]

Prognosis

  • Treatment and prognosis depend on the cause and cardiac status of the patient. This condition may be drug induced or it may be a result of cardiac disease.[equimedcorp.com]
  • Prognosis of sinus node dysfunction is mixed; without treatment, mortality is about 2%/yr, primarily resulting from an underlying structural heart disorder. Each year, about 5% of patients develop AF with its risks of heart failure and stroke.[msdmanuals.com]

Etiology

  • After reviewing the literature and discussing possible etiologies for this unusual adverse drug reaction in this setting, we recommend that metoclopramide be used with caution in patients prone to develop bradyarrythmias, particularly those with dysautonomias[ncbi.nlm.nih.gov]
  • 0.11 sec or less Etiology May occur with hypoxia, myocardial ischemia or infarction, hyperkalemia, medications (beta blockers, calcium channel blockers), and increased vagal tone Conduction SA node fails to initiate electrical impulse for one or more[ecgreview.weebly.com]
  • Etiology of sinus pauses and arrest: alteration in the impulse rate of the P cells. Therefore, the pause length is variable and not necessarily a multiple of the basic sinus rate.[hqmeded-ecg.blogspot.com]

Epidemiology

  • Epidemiology [ edit ] Sick sinus syndrome is a relatively uncommon syndrome in the young and middle-aged population.[en.wikipedia.org]
Sex distribution
Age distribution

Pathophysiology

  • It is therefore suggested that the underlying pathophysiology involved autonomic dysfunction.[ncbi.nlm.nih.gov]
  • It is therefore suggested that the underlying pathophysiology involved autonomie dysfunction.[nejm.org]
  • Pathophysiology of isolated systolic hypertension in elderly patients: Doppler echocardiographic insights. American Heart Journal . 122(2) : 528-34, 1991.[health.usf.edu]

Prevention

  • This report emphasizes that a sphenopalatine ganglion blockade can be employed in the treatment and prevention of sinus arrest associated with postherpetic trigeminal distribution neuralgia.[ncbi.nlm.nih.gov]
  • The episodes of bradycardia did not coincide with orotracheal manipulation, were not prevented by escalating doses of glycopyrrolate, and were not accompanied by AV conduction disturbance as is frequently seen during a transient increase in vagal tone[ncbi.nlm.nih.gov]
  • Avoiding irrigation of the exposed brain with high-temperature saline may prevent such an incident.[ncbi.nlm.nih.gov]
  • In 12 patients (70.6%) heart block was totally prevented by nCPAP.[ncbi.nlm.nih.gov]

References

Article

  1. Pikkujamsa SM, Makikallio TH, Sourander LB, et al. Cardiac interbeat interval dynamics from childhood to senescence: comparison of conventional and new measures based on fractals and chaos theory. Circulation. 1999;100(4):393–399.
  2. Csepe TA, Kalyanasundaram A, Hansen BJ, Zhao J, Fedorov VV. Fibrosis: a structural modulator of sinoatrial node physiology and dysfunction. Front Physiol. 2015; 6: 37.
  3. Alonso A., Jensen P. N., Lopez F. L., et al. Association of sick sinus syndrome with incident cardiovascular disease and mortality: the atherosclerosis risk in communities study and cardiovascular health study. PLoS ONE. 2014;9:e109662.
  4. Olshansky B, Chung MK, Pogwizd SM, Goldschlager N. Arrhythmia Essentials. Philadelphia, PA: Elsevier; 2016. ISBN: 9780323399685
  5. Ferrer MI, MD. Disturbances in sinus rhythm: sinus arrest, sino-atrial exit block. J Insur Med. 1994; 26(3):360-361.
  6. New York Heart Association. Criteria Committee.Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. Criteria, 8th ed. Boston, MA: Little Brown & Co., Boston;1979.
  7. Zipes DP. Cardiac Electrophysiology: From Cell to Bedside. Philadelphia, PA. Elsevier; 2014. ISBN: 9781455728565
  8. Crawford MH, Bernstein SJ, Deedwania PC, et al. ACC/AHA guidelines for ambulatory electrocardiography. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the Guidelines for Ambulatory Electrocardiography). Developed in collaboration with the North American Society for Pacing and Electrophysiology. J Am Coll Cardiol. 1999;34 (3):912-948.

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Last updated: 2019-07-11 22:24