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| {{Infobox_Disease
| | __NOTOC__ |
| | Name = {{PAGENAME}}
| | {{Sinus bradycardia}} |
| | Image = Sinusbrady.PNG
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| | Caption = Sinus bradycardia.
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| | DiseasesDB =
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| | ICD10 =
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| | ICD9 = {{ICD9|427.81}}
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| | ICDO =
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| | OMIM =
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| | MedlinePlus =
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| | eMedicineSubj = emerg
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| | eMedicineTopic =
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| | MeshID = D001146
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| }} | |
| {{SI}} | | {{SI}} |
| {{CMG}} | | {{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}} |
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| '''Associate Editor-In-Chief:''' {{CZ}}
| | ==[[Sinus bradycardia overview|Overview]]== |
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| {{Editor Join}}
| | ==[[Sinus bradycardia pathophysiology|Pathophysiology]]== |
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| '''Sinus [[bradycardia]]''' is a heart rhythm that originates from the sinus node and has a rate of under 60 beats per minute. Common causes include [[sick sinus syndrome]] and pharmacotherapy such as [[beta-blockers]]. Sinus bradycardia is not unexpected in highly trained athletes. It only requires treatment if the patient is symptomatic.
| | ==[[Sinus bradycardia causes|Causes]]== |
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| ==Pathosphysiology== | | ==[[Sinus bradycardia differential diagnosis|Differentiating Sinus bradycardia from other Diseases]]== |
| This rhythm may be caused by one of the following:
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| * Increased [[vagal]] tone.
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| * Intrinsic disease of the [[SA node]].
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| * An effect of [[drugs]], such as the use of [[digitalis]] or [[beta-blockers]].
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| * [[Sleep]]
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| * Sinus bradycardia is a normal finding in a healthy, well-conditioned athlete.
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| == Differential Diagnosis of Causes of Sinus Bradycardia== | | ==[[Sinus bradycardia epidemiology and demographics|Epidemiology and Demographics]]== |
| In alphabetical order. <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref> <ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</ref>
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| * [[Ambenonium]]
| | ==[[Sinus bradycardia risk factors|Risk Factors]]== |
| * [[Acetylcholine]]
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| * [[Alfentanil]]
| | ==[[Sinus bradycardia natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| * [[Amiodarone]]
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| * [[Amyloidosis]]
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| * [[Anorexia nervosa]]
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| * [[Atenolol]]
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| * [[Ativan]]
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| * [[Beta blocker]]
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| * [[Bethanechol]]
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| * [[Brucellosis]]
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| * [[Bupivacaine]]
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| * [[Calcium channel blocker]]
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| * [[Carotid sinus hypersensitivity]]
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| * [[Cardiac catheterization]]
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| * [[Cerebral edema]]
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| * [[Cervical spine injury]]
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| * [[Cilobradine]]
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| * [[Clonidine]]
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| * [[Congenital Heart Disease]]
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| * [[Corgard]]
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| * [[Coughing]]
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| * [[Cretinism]]
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| * [[Decompression sickness]]
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| * [[Deserpidine]]
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| * [[Diabetic]] autonomic neuropathy
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| * [[Digitalis]]
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| * [[Diltiazem]]
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| * [[Dimethyl sulfoxide]] ([[DMSO]])
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| * [[Diptheria]]
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| * [[Distigmine]]
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| * [[Drugs]]
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| * [[Dysautonomia]]
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| * [[Electrocution]]
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| * [[Fentanyl]]
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| * [[Fetal distress]]
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| * [[Glaucoma]]
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| * [[Glioblastoma]]
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| * [[High altitude]] sickness
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| * [[Hypercalcemia]]
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| * [[Hypercapnia]]
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| * [[Hyperkalemia]]
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| * [[Hypermagnesemia]]
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| * [[Hypoglycemia]]
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| * [[Hypothermia]]
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| * [[Hypothyroidism]]
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| * [[Hypoxia]]
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| * [[Increased intracranial pressure]]
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| * [[Ivabradine]]
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| * [[Kwashiorkor]]
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| * [[Lidocaine]]
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| * [[Lilly of the valley]]
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| * [[Lithium]]
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| * [[Lofexidine]]
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| * [[Malnutrition]]
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| * [[Meningitis]]
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| * [[Micturition syncope]]
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| * [[Miller-Dieker syndrome]]
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| * [[STEMI|Myocardial Infarction]], particularly inferior MI
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| * [[Myocarditis]]
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| * [[Nausea]]
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| * [[Nadolol]]
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| * [[Neostigmine]]
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| * [[Nerve gas]]
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| * [[Organophosphates]]
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| * [[Paclitaxel]]
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| * Physical training, elite athlete status
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| * [[Physostigmine]] ([[Eserine]] / [[Antrilirium]])
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| * [[Post-tussive syncope]]
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| * [[Procainamide]] ([[Procan-SR]] / [[Pronestyl]])
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| * [[Propranolol]]
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| * [[Quinidine]]
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| * [[Reserpine]]
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| * [[Rheumatic fever]]
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| * [[Sepsis]]
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| * [[Sick Sinus Syndrome]] ([[SSS]])
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| * [[Sleep apnea]]
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| * [[Sotalol]] ([[Betapace]])
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| * [[Spinal cord injury]]
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| * [[Starvation]]
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| * [[Subarachnoid hemorrhage]]
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| * [[Sufentanil]]
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| * [[Suxamethonium]]
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| * Tight fitting neckwear
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| * [[Toluene]]
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| * [[Tumor]]s of the neck
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| * [[Tumor lysis syndrome]]
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| * [[Typhoid Fever]]
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| * [[Vagal nerve]] stimulation
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| * [[Vagotonia]]
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| * [[Valsalva maneuver]]
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| * [[Vasovagal syncope]]
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| * [[Verapamil]]
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| * [[Vicodin]]
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| * [[Vomitting]]
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| * [[Yellow fever]]
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| * [[Zatebradine]]
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| ==Diagnosis== | | ==Diagnosis== |
| ===Symptoms===
| | [[Sinus bradycardia history and symptoms| History and Symptoms]] | [[Sinus bradycardia physical examination | Physical Examination]] | [[Sinus bradycardia laboratory findings|Laboratory Findings]] | [[Sinus bradycardia electrocardiogram|Electrocardiogram]] |
| The decreased heart rate can cause a decreased [[cardiac output]] resulting in symptoms such as [[lightheadedness]], [[dizziness]], [[hypotension]], [[vertigo]], and [[syncope]].
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| Sinus bradycardia may lead to no symptoms in a young athlete. | |
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| ===Signs===
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| There may be a wide [[pulse pressure]]. If [[cardiac output]] is reduced, there may be signs of end organ hypoperfusion.
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| ===Laboratory Studies===
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| [[TFT]]s should be checked
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| Check electrolytes, Ca, Mg
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| [[Hypoglycemia]] should be excluded
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| Consider a toxicologic screen
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| ===ECG Characteristics===
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| *Rate: Less than 60.
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| *Rhythm: Regular.
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| *[[P wave]]s: Upright, consistent, and normal in morphology and duration.
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| *[[PR Interval]]: Between 0.12-0.20 seconds in duration.
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| *[[QRS complex]]: Less than 0.12 seconds in width, and consistent in morphology.
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| *[[Early repolarization]] is accentuated in the setting of sinus bradycardia
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| ====EKG Examples====
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Sinusbrady.PNG|Sinus bradycardia
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| Image:Ecg_bradycardia 1.png|Sinus bradycardia
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| </gallery>
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| </div>
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| ==Treatment== | | ==Treatment== |
| ===Acute Management===
| | [[Sinus bradycardia medical therapy|Medical Therapy]] | [[Sinus bradycardia primary prevention|Primary Prevention]] |
| If a patient is symptomatic, intravenous access should be established. [[Atropine]] can be administered down an endotracheal tube or can be administered intravenously. The dose is 0.5-1 mg IV or ET q 3-5 min up to 3 mg total (0.04 mg/kg). The pediatric dosing is 0.02 mg/kg/dose IV, minimum of 0.1 mg. [[Isoproteronol]] ([[Isoprel]]) has been used in the past, but carries risks. Transcutaneous pacing can be undertaken while a temporary wire is being placed. Offending or exacerbating agents such as [[beta-blockers]], [[calcium channel blockers]] or [[digitalis]] should be discontinued and underlying causes treated. [[Sleep apnea]] is a common cause and should be treated with weight loss and BiPAP. Continuous monitoring in the hospital is recommended.
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| ===Chronic Management===
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| Asymptomatic sinus bradycardia requires no treatment. Patients with [[Sick Sinus Syndrome]] generally require a pacemaker.
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| ==ACC/AHA/HRS Guideline Recommendations for Pacemaker Implantation==
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| Recommendations for Permanent Pacing in Sinus Node Dysfunction
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| Class I
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| 1. Permanent pacemaker implantation is indicated for SND with documented symptomatic bradycardia, including
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| frequent sinus pauses that produce symptoms.(Level of Evidence: C)
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| 2. Permanent pacemaker implantation is indicated for symptomatic chronotropic incompetence. (Level of
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| Evidence: C)
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| 3. Permanent pacemaker implantation is indicated for symptomatic sinus bradycardia that results from required
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| drug therapy for medical conditions. (Level of Evidence: C)
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| Class IIa
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| 1. Permanent pacemaker implantation is reasonable for SND with heart rate less than 40 bpm when a clear
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| association between significant symptoms consistent with bradycardia and the actual presence of bradycardia
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| has not been documented. (Level of Evidence:C)
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| 2. Permanent pacemaker implantation is reasonable for syncope of unexplained origin when clinically significant
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| abnormalities of sinus node function are discovered or provoked in electrophysiological studies. (Level of Evidence: C)
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| Class IIb
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| 1. Permanent pacemaker implantation may be considered in minimally symptomatic patients with chronic heart rate less than 40 bpm while awake. (Level of Evidence: C)
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| Class III
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| 1. Permanent pacemaker implantation is not indicated for SND in asymptomatic patients. (Level of Evidence:C)
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| 2. Permanent pacemaker implantation is not indicated for SND in patients for whom the symptoms suggestive of bradycardia have been clearly documented to occur in the absence of bradycardia. (Level of Evidence:C)
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| 3. Permanent pacemaker implantation is not indicated for SND with symptomatic bradycardia due to nonessential drug therapy. (Level of Evidence: C)
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| | ==Case Studies== |
| | [[Sinus bradycardia case study one|Case#1]] |
| ==References== | | ==References== |
| {{Reflist|2}} | | {{Reflist|2}} |
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| == See also ==
| | [[Category:Cardiology]] |
| *[[Sinus tachycardia]]
| | [[Category:Up-To-Date]] |
| *[[Long QT syndrome]]
| | [[Category:Up-To-Date cardiology]] |
| | | [[Category:Arrhythmia]] |
| ==Additional resources==
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| * [http://en.ecgpedia.org ECGpedia: Course for interpretation of ECG]
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| * [http://www.anaesthetist.com/icu/organs/heart/ecg/ The whole ECG - A basic ECG primer]
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| * [http://www.ecglibrary.com 12-lead ECG library]
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| * [http://www.ecgsim.org Simulation tool to demonstrate and study the relation between the electric activity of the heart and the ECG]
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| * [http://heartcenter.seattlechildrens.org/what_to_expect/electrocardiogram.asp ECG information from Children's Hospital Heart Center, Seattle]
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| * [http://www.regionalpci-stemi.org/id10.html ECG Challenge from the ACC D2B Initiative]
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| * [http://0-www.nhlbi.nih.gov.innopac.up.ac.za:80/health/dci/Diseases/ekg/ekg_what.html National Heart, Lung, and Blood Institute, Diseases and Conditions Index]
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| * [http://www.ecglibrary.com/ecghist.html A history of electrocardiography]
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| * [http://www.health.gov.mt/impaedcard/issue/issue1/ipc00103.htm EKG Interpretations in infants and children]
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| [[Category:Electrophysiology]] | | [[Category:Electrophysiology]] |
| [[Category:Cardiology]] | | [[Category:Disease]] |
| [[Category:Emergency medicine]]
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| {{Electrocardiography}}
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| {{SIB}}
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| [[pl:Rzadkokurcz]]
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| [[sv:Sinusbradykardi]]
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| [[tr:Sinuzal bradikardi]]
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