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| Image = Sinus arrest.gif| | | Image = Sinus arrest.gif| |
| Caption = | | | Caption = | |
| DiseasesDB = |
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| ICD10 = {{ICD10|I|45|5|i|30}} |
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| ICD9 = {{ICD9|426.6}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = |
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| eMedicineSubj = |
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| eMedicineTopic = |
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| MeshID = D012848 |
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| }} | | }} |
| {{SI}} | | {{Sinoatrial arrest}} |
| | '''For patient information, click [[Sinoatrial arrest (patient information)|here]]''' |
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| {{CMG}} | | {{CMG}} |
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| ==Overview==
| | {{SK}} sinus arrest; sinus pause |
| Under certain circumstances, the [[SA node]] fails to initiate an impulse at the expected time in the [[cardiac cycle]]. In the absence of an impulse from the SA Node neither the atria nor the [[ventricle]]s are stimulated and thus an entire PQRST complex drops out for 1 beat(or more). This is called Sinoatrial(SA) Arrest. In other instances the impulse is initiated normally but is blocked within the SA Node and never reaches the atria and ventricles. This is called sinus exit block or sinoatrial block. Sinus arrest is one of several variants of [[sinus node dysfunction]]. The word sinus pause is used to indicate a pause in the generation of QRS complexes for 3 seconds or less. If the delay is longer than this, then the term sinus arrest is used. If there is a markedly prolonged or permanent cessation of [[P wave]] and [[QRS]] complexes, then the term a[[systole]] is applied.
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| ==Pathophysiology== | | ==[[Sinoatrial arrest overview|Overview]]== |
| If there is absence of a [[P wave]] or a dropped [[P wave]], it is difficult to determine from the surface EKG if this is 1) a loss of sinus node automaticity (sinus arrest) or 2) if this is a block of sinus node conduction (sinus exit block). This being said, there are some clinical observations below that help distinguish sinus arrest from sinus exit block.
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| ===Sinus arrest=== | | ==[[Sinoatrial arrest historical perspective|Historical Perspective]]== |
| There is no longer generation of pacemaker activity from the sinoatrial node. There is a failure of automaticity in the sinoatrial mode. The duration of the pause between beats is not a multiple of the heart rate (the P-P interval). In sinus arrest, there is also a suppression of other potential escape pacemakers in the atrium so that an atrial escape rhythm is rare.
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| ===Sinoatrial block=== | | ==[[Sinoatrial arrest pathophysiology|Pathophysiology]]== |
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| In this disorder, the sinoatrial node is generating electrical complexes, but the electrical activity fails to conduct in the atrium. Sinoatrial automaticity is preserved, and the [[P wave]]s are generated at a regular rate in a regular pattern which are a multiple of the basic sinus cycle. In patients with sinus exit block, the block is more frequently associated with either an atrial or an AV junctional escape rhythm.
| | ==[[Sinoatrial arrest causes|Causes]]== |
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| ====First degree SA exit block==== | | ==[[Sinoatrial arrest differential diagnosis|Differentiating Sinoatrial arrest from other Diseases]]== |
| There is a conduction delay (a slowing of conduction not a block or completion cessation in electrical conduction) in the impulse traveling from the [[sinus node]] to the [[atrium]] and there are no discernible changes on the surface EKG.
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| ====Second Degree SA exit blocks==== | | ==[[Sinoatrial arrest epidemiology and demographics|Epidemiology and Demographics]]== |
| This condition refers to intermittent conduction block (not a delay or slowing of conduction but a completion cessation of conduction) between the sinus node and the atrium.
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| =====Type I (Wenckebach phenomenon) sinoatrial exit block=====
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| This is an example of group beating. The P-P cycle (time between two [[P wave]]s)is progressively shortened until there is a pause. This pause is less than twice the shortest P-P interval. The cycle is then repeated. The pause is due to the dropped P wave and measures less than twice the P-P cycle. It is similar to the behavior of the RR intervals in type I second-degree AV block.
| | ==[[Sinoatrial arrest risk factors|Risk Factors]]== |
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| =====Type II second-degree sinoatrial exit block===== | | ==[[Sinoatrial arrest natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| There is an unexpected drop of the P wave. Following this drop, there is a pause in the sinus cycle which is a multiple of the basic sinus cycle. Blocked atrial premature beats sometimes mimic second-degree sinoatrial block.
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| =====Third-degree sinoatrial exit block=====
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| This SA block cannot be distinguished from sinus arrest when the sinus node ceases to fire. Under such circumstances, subsidiary pacemakers in the AV junction or ventricles may take over.
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| ==Causes==
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| *[[Acetylcholine]]
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| *[[Carotid sinus hypersensitivity]]
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| *Cough related [[syncope]] in patients with [[sick sinus syndrome]]
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| *[[Digitalis]] including digitalis toxicity
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| *[[Endotracheal intubation]] due to heightened [[vagal tone]]
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| *[[Hyperkalemia]]
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| :* Decreased [[P wave]] amplitude occurs when the K is > 7.0 meq/li
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| :* [[P wave]]s may be absent when the K is > 8.8 meq/li
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| :* The impulses are still being generated in the [[SA node]] and are conducted to the ventricles through specialized atrial fibers without depolarizing the atrial muscle
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| :* Moderate or sever hyperkalemia can cause [[sinus arrest]] <ref name="pmid16792034">{{cite journal |author=Bonvini RF, Hendiri T, Anwar A |title=Sinus arrest and moderate hyperkalemia |journal=[[Annales De Cardiologie Et D'angéiologie]] |volume=55 |issue=3 |pages=161–3 |year=2006 |month=June |pmid=16792034 |doi= |url= |issn=}}</ref>
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| *[[Lidocaine]]
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| *[[Myocarditis]]
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| *Percutaneous coronary intervention of the proximal right coronary artery can obstruct the origin of the SA nodal artery in about 17% of patients (14 of 80 in one series). <ref>Munenori Kotoku, Akira Tamura, Shigeru Naono and Junichi Kadota.Sinus arrest caused by occlusion of the sinus node artery during percutaneous coronary intervention for lesions of the proximal right coronary artery. Heart and vessels,2007, p.389-392</ref> Sinus arrest with junctional escape rhythm went on to develop in 4 of the 14 patients and one patient required a temporary ventricular pacing. There was resolution of the the junctional escape rhythm in all patients within 3 days of the sinus node artery occlusion.
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| *Nasal stimulation as part of a nsaocardiac reflex similar to the oculocardiac reflex during [[alfentanil]] - [[nitrous oxide]] anesthesia
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| *[[Quinidine sulfate]]
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| *[[Sinus node]] degeneration
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| *[[Sleep apnea]]
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| *[[ST elevation myocardial infarction]] particularly inferior myocardial infarctions and posterior infarctions.
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| *[[Vagal reaction|Vagal tone]]
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| ==Epidemiology and Demographics== | |
| Sinus arrest is fairly uncommon. It is more likely to be observed in elderly patients with a senescent rhythm system. It can be observed in the setting of myocardial disease ([[myocarditis]]) and ischemia or infarction (particularly acute inferior or posterior [[ST segment elevation MI]]). It can be a manifestation of [[digitalis]] or [[lidocaine]] toxicity.
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| ==Diagnosis== | | ==Diagnosis== |
| ===Symptoms===
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| If the AV junctional or ectopic ventricular pacemaker is not sufficiently rapid to generate an adequate cardiac output, then end organ hypoperfusion may result with some of the following symptoms:
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| *[[Angina]]
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| *[[Anxiety]]
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| *[[Confusion]]
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| *[[Congestive heart failure]]
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| *[[Dizziness]]
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| *[[Fainting]]
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| *[[Fatigue]]
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| *[[Lightheadedness]]
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| *[[Palpitations]]
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| *[[Syncope]]
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| ===Laboratory studies===
| | [[Sinoatrial arrest history and symptoms|History and Symptoms ]] | [[ Sinoatrial arrest physical examination|Physical Examination]] | [[Sinoatrial arrest laboratory findings|Laboratory Findings]] | [[Sinoatrial arrest electrocardiogram|Electrocardiogram]] | [[Sinoatrial arrest chest x ray|Chest X Ray]] | [[Sinoatrial arrest echocardiography|Echocardiography]] | [[Sinoatrial arrest other imaging findings|Other Imaging Findings]] | [[Sinoatrial arrest other diagnostic studies|Other Diagnostic Studies]] |
| Serum K+, Ca+ and Na+ should be checked as should [[thyroid function tests]] to rule out [[hypothyroidism]].
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| ===EKG Examples===
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| [[Image:Sinusarrest.png|thumb|center|500px|The sinus node stops firing resulting in a pause in heart beats]] | |
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| ==Treatment== | | ==Treatment== |
| ===Acute===
| | [[Sinoatrial arrest medical therapy|Medical Therapy]] | [[Sinoatrial arrest surgery |Surgery]] | [[Sinoatrial arrest primary prevention|Primary Prevention]] | [[Sinoatrial arrest secondary prevention|Secondary Prevention]] | [[Sinoatrial arrest cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Sinoatrial arrest future or investigational therapies|Future or Investigational Therapies]] |
| * Discontinue the agent that may be causing sinus arrest and treat [[hyperkalemia]].
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| * Isoproterenol can be used to increase the rate of the escape pacemaker.
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| * Atropine can be given if the block may be due to heightened vagal tone
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| * Finally, a temporary pacemaker wire can be placed if the patient is symptomatic with end organ hypoperfusion as a result of the AV nodal or ventricular escape rhythm.
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| ===Chronic===
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| *If sinus arrest is part of a chronic condition of [[sinus node dysfunction]] such as the [[tachycardia-bradycardia syndrome]] and if the patient is symptomatic, then permanent pacemaker placement may be neccessary.
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| ==References== | | ==Case Studies== |
| {{reflist|2}}
| | [[Sinoatrial arrest case study one|Case #1]] |
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| {{Electrocardiography}} | | {{Electrocardiography}} |
| | | [[Category:Electrophysiology]] |
| | | [[Category:Disease]] |
| [[Category:Cardiology]] | | [[Category:Cardiology]] |
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