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Revision as of 20:07, 29 August 2013

For patient information, click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahmoud Sakr, M.D. [2]

Synonyms and keywords:

Overview

The sinoatrial (SA) node represents the original pacemaker of the heart. It's formed of cells, sometimes called P cells, in a compact region at the junction of the high right atrium and the superior vena cava. The surrounding cells or Perinodal cells, sometimes called (T) cells, transmit the electrical impulse from the SA node to the right atrium. Each of these cell types has distinct expression profiles of ion channels and gap junctions. SA nodal dysfunction typically results from either abnormalities in signal generation by the P cells or abnormalities in conduction across the T cells. Sinoatrial nodal dysfunction includes pauses, arrest, exit block and ultimately sick sinus syndrome. Here we will discuss sinoatrial block.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Causes by Organ System

Cardiovascular	Acute coronary syndrome, acute rheumatic fever, Andersen cardiodysrhythmic periodic paralysis, Brugada syndrome, cardiac lymphoma, cardiac tumor, cardio inhibitory syncope, congenital heart disease, congestive heart failure, coronary reperfusion therapy, dilated cardiomyopathy, hypertensive heart disease, hypertrophic cardiomyopathy, ischemic heart disease, Jervell and Lange-Nielsen syndrome, long QT syndrome, myocardial infarction, myocardial rupture, myocarditis, NSTEMI, pericarditis, Romano-Ward syndrome, sick sinus syndrome, sinus bradycardia, sinus node fibrosis, STEMI, tachycardia-bradycardia syndrome, Timothy syndrome, valvular heart disease
Chemical / poisoning	Berberine, grayanotoxin, organophosphate poisoning, parathion poisoning, pyrethroid poisoning, scorpion toxin
Dermatologic	No underlying causes
Drug Side Effect	Acetylcholine, alfentanil, amiodarone, anthracyclines, barbiturate, beta-blockers, bortezomib, bupivacaine, calcium channel blockers, cholinesterase inhibitors, clonidine, dexmedetomidine, digitalis, digoxin, diltiazem, donepezil, edrophonium, fentanyl, flecainide, granisetron, guanethidine, guanfacine, halothane, ibutilide, idarubicin, lacosamide, lidocaine, lithium, magnesium, mepivacaine, mesalamine, methyldopa, mexiletine, neostigmine, nitrous oxide, pentostatin, phenothiazine, phenytoin, procainamide, propafenone, propofol, pyridostigmine, quinidine, remifentanil, rescinnamine, reserpine, rilmenidine, ropivacaine, tacrine, thiamylal, vecuronium, verapamil
Ear Nose Throat	No underlying causes
Endocrine	Diabetic ketoacidosis, thyrotoxic periodic paralysis, pheochromocytoma, profound hypothyroidism
Environmental	Berberine, hypothermia, poisonous spider bites, scorpion toxin
Gastroenterologic	No underlying causes
Genetic	Andersen cardiodysrhythmic periodic paralysis, Brugada syndrome, congenital heart disease, Emery-Dreifuss muscular dystrophy, Jervell and Lange-Nielsen syndrome, Kearns-Sayre syndrome, limb-girdle muscular dystrophy type 1B (LGMD1B), muscular dystrophy, myotonic dystrophy, Romano-Ward syndrome, Timothy syndrome
Hematologic	Hemochromatosis, multiple myeloma
Iatrogenic	Cardiac catheterization, cardiac transplantation, coronary artery bypass grafting, Fontan procedure, heart surgery, infraclavicular brachial plexus block, Maze procedure, post catheter ablation for arrhythmias
Infectious Disease	Acute rheumatic fever, Chagas disease, diptheria, Lyme disease, myocarditis, pericarditis, septic shock, sarcoidosis, systemic lupus erythematosus, tuberculosis
Musculoskeletal / Ortho	Muscular dystrophy, myotonic dystrophy, Timothy syndrome
Neurologic	Carotid sinus hypersensitivity, lateral medullary syndrome, vagal reaction
Nutritional / Metabolic	Hypermagnesemia, metabolic acidosis
Obstetric/Gynecologic	No underlying causes
Oncologic	Cardiac lymphoma, cardiac tumor, multiple myeloma, pheochromocytoma
Opthalmologic	Sjogren's syndrome
Overdose / Toxicity	Acetylcholine, amiodarone, anthracyclines, barbiturate, bortezomib, cholinesterase inhibitors, digitalis, edrophonium, nitrous oxide, phenytoin, propofol
Psychiatric	Takotsubo cardiomyopathy, severe anorexia nervosa
Pulmonary	Hypoxia, sleep apnea
Renal / Electrolyte	Acute renal failure, hyperkalemia
Rheum / Immune / Allergy	Acute rheumatic fever, sarcoidosis, Sjogren's syndrome, scleroderma
Sexual	No underlying causes
Trauma	Myocardial contusion, myocardial rupture, severe brain injury
Urologic	No underlying causes
Dental	No underlying causes
Miscellaneous	Amyloidosis

Causes in Alphabetical Order

Differentiating Sinoatrial block from other Diseases

Other types of types of SA nodal dysfunction are discussed in detail in other chapters on wikidoc. Follow the hyperlinks for details and those include:

Sinus pause or sinus arrest; this abnormality is an alteration in discharge by the SA pacemaker; as a result, the duration of the pause is variable and presents as a pause with no P waves on EKG.
Sinus arrhythmia; small changes in the sinus cycle length. The formal definition of sinus arrhythmia is a variation in the P-P interval by 0.12 sec (120 msec) or more in the presence of normal P waves and the usual PR interval. This type is common in the young, usually related to variation with respirations and is not considered abnormal.
Wandering atrial pacemaker; which represents three or more ectopic foci within the atrial myocardium that serve as the dominant pacemaker.
Sick sinus syndrome

Diagnosis

Treatment

References

↑ Bailey PL (1990). "Sinus arrest induced by trivial nasal stimulation during alfentanil-nitrous oxide anaesthesia". Br J Anaesth. 65 (5): 718–20. PMID 2248851.
↑ ^2.0 ^2.1 ^2.2 Mills TA, Kawji MM, Cataldo VD, Pappas ND, O'Meallie LP, Breaux DM; et al. (2004). "Profound sinus bradycardia due to diltiazem, verapamil, and/or beta-adrenergic blocking drugs". J La State Med Soc. 156 (6): 327–31. PMID 15688675.
↑ ^3.0 ^3.1 Lines D, Shipton EA (1991). "Severe bradycardia and sinus arrest after administration of vecuronium, fentanyl and halothane. A case report". S Afr Med J. 80 (4): 200–1. PMID 1678901.
↑ Bonvini RF, Hendiri T, Anwar A (2006). "Sinus arrest and moderate hyperkalemia". Annales De Cardiologie Et D'angéiologie. 55 (3): 161–3. PMID 16792034. Unknown parameter |month= ignored (help)
↑ Koay S, Dewan B (2013). "An unexpected Holter monitor result: multiple sinus arrests in a patient with lateral medullary syndrome". BMJ Case Rep. 2013. doi:10.1136/bcr-2012-007783. PMID 23386489.

Template:WikiDoc Sources

[pmid2248851-1] Bailey PL (1990). "Sinus arrest induced by trivial nasal stimulation during alfentanil-nitrous oxide anaesthesia". Br J Anaesth. 65 (5): 718–20. PMID 2248851.

[pmid15688675-2] 2.0 ^2.1 ^2.2 Mills TA, Kawji MM, Cataldo VD, Pappas ND, O'Meallie LP, Breaux DM; et al. (2004). "Profound sinus bradycardia due to diltiazem, verapamil, and/or beta-adrenergic blocking drugs". J La State Med Soc. 156 (6): 327–31. PMID 15688675.

[pmid1678901-3] 3.0 ^3.1 Lines D, Shipton EA (1991). "Severe bradycardia and sinus arrest after administration of vecuronium, fentanyl and halothane. A case report". S Afr Med J. 80 (4): 200–1. PMID 1678901.

[pmid16792034-4] Bonvini RF, Hendiri T, Anwar A (2006). "Sinus arrest and moderate hyperkalemia". Annales De Cardiologie Et D'angéiologie. 55 (3): 161–3. PMID 16792034. Unknown parameter |month= ignored (help)

[pmid23386489-5] Koay S, Dewan B (2013). "An unexpected Holter monitor result: multiple sinus arrests in a patient with lateral medullary syndrome". BMJ Case Rep. 2013. doi:10.1136/bcr-2012-007783. PMID 23386489.

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@@ Line 293: / Line 293: @@
 ==Differentiating Sinoatrial block from other Diseases==
-Other types of types of SA nodal dysfunction include:
+Other types of types of SA nodal dysfunction are discussed in detail in other chapters on wikidoc. Follow the hyperlinks for details and those include:
 *[[Sinus pause]] or [[sinus arrest]]; this abnormality is an alteration in discharge by the SA pacemaker; as a result, the duration of the pause is variable and presents as a pause with no P waves on EKG.
 *[[Respiratory sinus arrhythmia|Sinus arrhythmia]]; small changes in the sinus cycle length. The formal definition of sinus arrhythmia is a variation in the P-P interval by 0.12 sec (120 msec) or more in the presence of normal P waves and the usual PR interval. This type is common in the young, usually related to variation with respirations and is not considered abnormal.