Sustained symptomatic sinus node reentrant tachycardia: incidence, clinical significance, electrophysiologic observations and the effects of antiarrhythmic agents
Open accessAbstract
The clinical, electrocardiographic and electrophysiologic determinants and effects of antiarrhythmic agents on sustained sinus node reentrant tachycardia remain poorly defined. Of 65 consecutive men undergoing electrophysiologic studies for symptomatic paroxysmal supraventricular tachycardia over a 4 year period, 11 (16.9%), who ranged in age from 39 to 76 years, demonstrated sustained sinus node reentrant tachycardia. On the surface electrocardiogram, before electrophysiologic studies, the following diagnoses were considered in the 11 patients: sinus node reentrant tachycardia on the basis of an RP'/P'R ratio of greater than 1 and P wave configuration similar to that of sinus P waves (7 patients); atrioventricular (AV) nodal reentrant tachycardia on the basis of an RP'/P'R ratio of less than 1 (3 patients); and paroxysmal atrial tachycardia with AV block (1 patient). All 11 patients had a history of recurrent palpitation, 4 had syncope, 2 had dizzy spells and 9 had organic heart disease. Sustained sinus node reentrant tachycardia could be reproducibly induced in all 11 patients during atrial pacing or premature atrial stimulation, or both, over a wide echo zone. The tachycardia could be terminated by carotid sinus massage, atrial pacing and premature atrial stimulation. Characteristics of tachycardia included: high-low activation sequence; cycle lengths of 250 to 590 ms with wide fluctuations of 20 to 180 ms in individual patients; RP'/P'R ratio of greater than 1 in 8 (73%) of the 11 patients and a ratio of less than 1 in 3 (27%). Induction of sustained sinus node reentrant tachycardia was prevented by intravenous ouabain (0.01 mg/kg body weight) in two of two patients, by intravenous verapamil (10 mg) in two of two patients and by intravenous amiodarone (5 mg/kg body weight) in four of four patients. In contrast, intravenous propranolol (0.1 mg/kg body weight) did not affect induction of sustained sinus node reentrant tachycardia in two of two patients. It is concluded that sustained sinus node reentrant tachycardia, seen in 16.9% of the study patients with paroxysmal supraventricular tachycardia, is not as benign as previously believed; it is frequently associated with organic heart disease; it demonstrates wide variations in cycle length, unlike other forms of paroxysmal supraventricular tachycardia; it can masquerade as AV nodal reentrant tachycardia and paroxysmal atrial tachycardia with AV block on the surface electrocardiogram in 36% of patients; and it is responsive to intravenous administration of ouabain, verapamil or amiodarone.
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Sinus node reentrant tachycardia is easily and reproducibly induced with programmed atrial stimulation, unlike inappropriate sinus tachycardia.
“sinus node reentrant tachycardia is easily and reproducibly induced with programmed atrial stimulation differently from inappropriate sinus tachycardia;”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [92]
Verapamil, digoxin, and amiodarone have variable success in sinus node reentrant tachycardia; beta-blockers are often ineffective; ivabradine likely has minimal benefit.
“Verapamil, digoxin, and amiodarone have demonstrated variable success while beta-blockers are often ineffective, and the potential benefit of ivabradine is likely to be minimal.92,98”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [92]
The mechanism of sinus node reentrant tachycardia is independent of AV node conduction.
“demonstration of the arrhythmia mechanism independent of the AV node conduction;”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [92]
In sinus node reentrant tachycardia, earliest activation is localized to the sinus node area in the superior crista terminalis, as in sinus rhythm.
“earliest activation is localized to the area of sinus node in the region of superior crista terminalis as happens with sinus rhythm;”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [92]
Sinus node reentrant tachycardia can be acutely terminated by vagal manoeuvres, adenosine, atrial pacing, and premature atrial stimulation.
“the tachycardia can be acutely terminated by vagal manoeuvres, adenosine, atrial pacing and premature atrial stimulation.92”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [92]
Pacing manoeuvres such as entrainment can confirm the reentry mechanism in sinus node reentrant tachycardia.
“pacing manoeuvres such as entrainment can confirm the reentry mechanism;”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [92]
In sinus node reentrant tachycardia, heart rate can shift suddenly at initiation, as opposed to the gradual increase in inappropriate sinus tachycardia.
“the heart rate can shift suddenly at initiation of sinus node reentrant tachycardia, as opposed to the gradual increase of the inappropriate sinus tachycardia rate;”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [92]
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Cites
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- Authors
- Gomes, J. A., Hariman, R. J., Kang, P. S., & Chowdry, I. H.
- Corresponding author
- Gomes, Joseph A.
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 1985-01
- Volume
- 5
- Issue
- 1
- Pages
- 45-57
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W1977280168
- Cited by
- 78
- References
- 22
- Citations by year
- 2025: 1 · 2024: 1 · 2023: 2 · 2022: 1 · 2021: 5 · 2020: 3 · 2019: 1 · 2017: 2 · 2016: 2 · 2015: 3 · 2014: 1 · 2013: 2 · 2012: 3
- FWCI
- 1.74
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
- Keywords
- paroxysmal supraventricular tachycardia, atrioventricular nodal reentrant tachycardia, atrial pacing, carotid sinus massage, ouabain, verapamil, amiodarone, propranolol, antiarrhythmic drugs
- MeSH terms
- Adult, Aged, Amiodarone, Anti-Arrhythmia Agents, Electrocardiography, Electrophysiology, Humans, Male, Middle Aged, Ouabain, Propranolol, Sinoatrial Node, Tachycardia, Tachycardia, Paroxysmal, Time Factors, Verapamil
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