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Sick sinus syndrome

Key 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 Japanese Heart Rhythm Society (JHRS/JCS 2022; 2021), the Heart Rhythm Society (HRS 2022), 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.Diagnostic investigations

History and physical examination: elicit a comprehensive history and perform a physical examination in patients with suspected bradycardia.
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  • Resting ECG

  • Exercise ECG

  • Ambulatory ECG monitoring

  • Diagnostic imaging

  • Laboratory testing

  • Sleep evaluation

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.

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  • Electrophysiology study

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.

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  • Addressing reversible causes

  • Atropine

  • Beta-adrenergic agonists

  • Theophylline and aminophilline

  • Phosphodiesterase-3 inhibitors

4.Therapeutic procedures

Temporary pacing, transvenous, ESC: perform temporary transvenous pacing in patients with hemodynamic-compromising bradyarrhythmia refractory to IV chronotropic drugs.
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  • Temporary pacing (transcutaneous)

  • Permanent pacing (indications, asymptomatic bradycardia)

  • Permanent pacing (indications, symptomatic bradycardia)

  • Permanent pacing (shared decision-making)

  • Permanent pacing (pre-implantation assessment)

  • Permanent pacing (peri-implantation care)

  • Permanent pacing (choice of leads)

  • Permanent pacing (singl- versus dual-chamber pacing)

  • Permanent pacing (septum pacing)

  • Permanent pacing (CRT)

  • Permanent pacing (remote monitoring)

  • Permanent pacing (considerations for MRI)

  • Permanent pacing (discontinuation)

5.Perioperative care

Prophylactic perioperative 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.
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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 β-blocker overdose.
Consider administering high-dose insulin to increase HR and improve symptoms in patients with bradycardia associated with symptoms or hemodynamic compromise caused by β-blocker overdose.

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  • Patients with CCB toxicity

  • Patients with digoxin toxicity

  • Patients with tachycardia-bradycardia syndrome (permanent pacing)

  • Patients with tachycardia-bradycardia syndrome (AF ablation)

  • Patients with acute myocardial infarction

  • Patients with Lyme carditis

  • Patients with congenital heart disease

  • Patients after cardiac surgery

  • Patients after heart transplantation

  • Patients with obstructive sleep apnea

  • Patients with accidental hypothermia

  • Patients with acute spinal cord injury

  • Patients with neuromuscular disorders