Mechanism of ”inappropriate” sinus tachycardia. Role of sympathovagal balance
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BACKGROUND: "Inappropriate" sinus tachycardia (IST) is an uncommon and poorly defined atrial tachycardia characterized by inappropriate tachycardia and exaggerated acceleration of heart rate with "normal" P wave. The mechanism of this tachycardia is unknown. The purpose of the present study was to determine the role of autonomic balance in the genesis of IST. METHODS AND RESULTS: Six female patients aged 23 to 38 years with IST and 10 age- and sex-matched control subjects were assessed with the following autonomic function tests: (1) sympathovagal balance to the sinus node assessed by calculating the LF/HF (low frequency/high frequency) ratio using power spectral analysis both in the supine position and after 10 minutes of head-up tilt to 60 degrees, (2) cardiovagal reflex assessed by cold face test (CFT), (3) beta-adrenergic sensitivity as determined by calculating isoproterenol dose-response curves and isoproterenol chronotropic dose 25 (CD25), and (4) intrinsic heart rate (IHR) assessed after autonomic blockade with atropine 0.04 mg/kg and propranolol 0.2 mg/kg administered as an intravenous bolus. No significant differences in the LF/HF ratio both in the supine position (2.8 +/- 0.3 versus 2.6 +/- 0.4) and during upright tilt (8.7 +/- 1.3 versus 8.5 +/- 0.5) were observed between control subjects and IST patients. Cardiovagal response to CFT was markedly depressed in all patients (6.3% IST patients versus 24.2% control subjects, P < .001). beta-Adrenergic hypersensitivity to isoproterenol was noted in all patients (mean CD25, 0.29 +/- 0.10 microgram IST patients versus 1.27 +/- 0.4 microgram control subjects; P < .001), and high IHR was noted in all cases. The patients were treated with high doses of beta-blockers with adequate short-term control. Radiofrequency catheter ablation of the sinus node area was performed in one drug-refractory patient. CONCLUSIONS: These findings suggest that the mechanism leading to IST is related to a primary sinus node abnormality characterized by a high IHR, depressed efferent cardiovagal reflex, and beta-adrenergic hypersensitivity.
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Treadmill exercise testing may help document an exaggerated tachycardic response to exertion, but this has not been validated.
“Treadmill exercise testing might be useful to document an exaggerated tachycardic response to exertion,59 although this assertion has not been validated.”
Morillo et al studied 6 patients with IST and showed that while patients had higher intrinsic heart rates indicative of increased sinus node automaticity, they had depressed vagal outflow and increased β-adrenergic sensitivity.
“In particular, Morillo et al studied 6 patients with IST using a battery of autonomic testing including heart rate variability analysis, cardiovagal reflex testing using cold face testing, and autonomic blockade with intravenous propranolol and atropine.57 These investigators showed that while patients had higher intrinsic heart rates indicative of increased sinus node automaticity, they had”
From Sinus Tachycardia: a Multidisciplinary Expert Focused Review (2022) · cites this paper as [57]
Studies of patients with IST demonstrated, through pharmacologic autonomic blockade, that sympathetic tone is elevated in IST.
“These studies demonstrated, through pharmacologic autonomic blockade, that sympathetic tone is elevated in IST.57,58”
From Sinus Tachycardia: a Multidisciplinary Expert Focused Review (2022) · cites this paper as [57]
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- Authors
- Morillo, C. A., Klein, G. J., Thakur, R. K., Li, H., Zardini, M., & Yee, R.
- Affiliations
- Western University (CA)
- Venue
- Circulation
- Published
- 1994-08
- Volume
- 90
- Issue
- 2
- Pages
- 873-877
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- OpenAlex
- W1982423666
- Cited by
- 193
- References
- 16
- Citations by year
- 2026: 2 · 2025: 1 · 2024: 2 · 2023: 3 · 2022: 7 · 2021: 10 · 2020: 6 · 2019: 7 · 2018: 5 · 2017: 3 · 2016: 3 · 2015: 5 · 2014: 6 · 2013: 12 · 2012: 12
- FWCI
- 3.78
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Circulation (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Heart and Stroke Foundation of Canada
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Keywords
- inappropriate sinus tachycardia, sympathovagal balance, sinoatrial node, autonomic dysfunction, intrinsic heart rate, beta-blockers, radiofrequency catheter ablation, heart rate variability, head-up tilt, propranolol, atropine
- MeSH terms
- Adrenergic beta-Antagonists, Adult, Autonomic Nerve Block, Female, Heart Rate, Humans, Hypotension, Orthostatic, Isoproterenol, Receptors, Adrenergic, beta, Reflex, Sinoatrial Node, Sympathetic Nervous System, Tachycardia, Sinus, Vagus Nerve
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