6, 2014
EDITORIAL COMMENT
Gordon A. Ewy, MD
(e.g., syncope, dizziness, bradycardia, sinus pauses), An asystole response of 3 or more seconds to carotid
with no evidence of other conditions responsible for sinus pressure is strongly suggestive of SSS and an
the episode, such as atrioventricular block or medi- indication for a permanent pacemaker if the patient
cation use (7). These investigators conrmed that the has a history of syncope (8).
incidence of SSS increased with age, but found that The denitive diagnosis is often made by ambu-
blacks had a lower risk than whites. They reported latory monitoring or by electrophysiological studies.
that the incidence of SSS was associated with greater Modern ambulatory monitoring alternatives are often
body mass index, greater height, longer QRS interval, essential to this diagnosis. The increasing sophisti-
lower heart rate, and prevalent hypertension, right cation, diagnostic ability, and surgical skills of the
bundle branch block, and cardiovascular disease (7). modern electrophysiologists make the diagnosis easy
The SSS may be difcult to diagnosis, because and therapy of patients with SSS effective. Jensen
initially, the symptoms may be mild and very inter- et al. (7) predict that with the aging of our population,
mittent. When the patient presents with symptoms SSS will be a major factor in increasing the need for
consistent with SSS, a detailed history of medica- permanent pacemakers. This fact will drive research
tions, including alternative medications, is essential. into more effective approaches to the diagnosis of
In addition, it is rare, but the patient may be taking the SSS and into decreasing the size and type of
the same medication prescribed by 2 different phy- permanent pacemakers, as well as increasing the
sicians: one by a generic name and the other by a sophistication of future permanent pacemakers.
trade name, such as metoprolol and Toprol-XL, or
digoxin and Lanoxin, where known side effects of REPRINT REQUESTS AND CORRESPONDENCE: Dr.
overdose are arrhythmias consistent with SSS. Gordon A. Ewy, Department of Medicine, University
The physical examination and the electrocardio- of Arizona Sarver Heart Center, 932 West San Martin
gram are important, including performing carotid si- Drive, Tucson, Arizona 85704. E-mail: gaewy1933@
nus pressure, while observing the electrocardiogram. gmail.com.
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and conduction disturbances. In: Ewy GA, sinus node disorders. Arch Intern Med 1982;142: report of the American College of Cardiology/
Bressler R, editors. Cardiovascular Drugs and the 3712. American Heart Association Task Force on Prac-
Management of Heart Disease. New York, NY: tice Guidelines (Writing Committee to Revise the
6. Birnie D, Williams K, Guo A, et al. Reasons for
Raven Press, 1982:44162. ACC/AHA/NASPE 2002 Guideline Update for
escalating pacemaker implants. J Am Coll Cardiol
Implantation of Cardiac Pacemakers and Anti-
2. Gregoratos G. Sick sinus syndrome. Circulation 2006;98:937.
arrhythmia Devices). J Am Coll Cardiol 2008;
2003;108:e1434.
7. Jensen PN, Gronroos NN, Chen LY, et al. Inci- 51:e162.
3. Short DS. The syndrome of alternating dence of and risk factors for sick sinus syndrome
bradycardia and tachycardia. Brit Heart J 1954;16: in the general population. J Am Coll Cardiol 2014;
20814. 64:5318.
4. Ferrer MI. The sick sinus syndrome in atrial 8. Epstein AE, DiMarco JP, Ellenbogen KA, et al. KEY WORDS cardiac arrest, passive
disease. JAMA 1967;206:62546. ACC/AHA/HRS 2008 guidelines for device-based ventilation, prevention, ventricular brillation