JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
6, 2014
2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
PUBLISHED BY ELSEVIER INC.
EDITORIAL COMMENT
Sick Sinus Syndrome
Synopsis*
Gordon A. Ewy, MD
S ick sinus syndrome (SSS) is a term used for a
variety of cardiac arrhythmias, occurring pre-
dominantly in the elderly, that result from a
senescent sinus node. Because the sinus node is the
normal pacemaker of the heart, its dysfunction is a
cause for concern. Although the major problem is
failure of the sinoatrial node, the symptoms would
be uncommon were it not for the diffuse nature of
the dysfunction, accounting for the frequent failure
of escape or rescue rhythms. Accordingly, SSS is char-
acterized, not only by sinus node malfunction, result-
ing in intermittent sinus pauses and rare sinus arrest,
but also by inappropriate and often intermittent
bradycardia, tachycardia, and the frequent alterna-
tion between the 2 conditions (tachycardia-brady-
cardia syndrome) (1,2).
When sinus node dysfunction is associated with
symptoms, or prolonged periods of asystole, it is
referred to as the sick sinus syndrome. Although Dr.
Short (3) had previously published on The Syndrome
of Alternating Bradycardia and Tachycardia, Dr.
Ferrer (4) was evidently the rst, in 1968, to use the
term sick sinus syndrome to describe the sluggish re-
turn of sinoatrial nodal function in patients following
electrical cardioversion.
Sick sinus syndrome is generally a disease of aging.
It is uncommon in children. If present in children, it
was usually acquired post-operatively as a result of
trauma to the atrium during cardiac surgery to correct
congenital heart defects.
A characteristic feature of SSS is that the heart does
not respond normally to stimuli that should produce
increased heart rates, such as exercise. Because SSS
*Editorials published in the Journal of the American College of Cardiology
reect the views of the authors and do not necessarily represent the
views of JACC or the American College of Cardiology.
From the University of Arizona Sarver Heart Center, Tucson, Arizona.
Dr. Ewy has reported that he has no relationships relevant to the
contents of this paper to disclose.
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is most common in the elderly, its symptoms may be
attributed to the aging process rather than to a dis-
ease. One of the hallmarks of aging is the progressive
loss of cells, and this loss of cells in the sinus node is
a commonly reported pathological nding in patients
with SSS. The frequent lack of an effective escape
rhythm emphasizes the diffuse nature of the con-
duction system disease. Because the sinus node gets
its blood supply from a branch of a coronary artery,
SSS also can be caused by atherosclerosis and may
be associated with angina. The syndrome can be
accompanied by a variety of other supraventricular
arrhythmias. Although the rescue rhythms are usu-
ally atrial, the association of atrioventricular nodal
disease is not uncommon.
Clinically signicant SSS often requires pacemaker
implantation. Ferrer (5) pointed out in 1982 that one-
half of the 60,000 pacemakers implanted were for
SSS. By 2006, SSS was one of the most common rea-
sons for the escalating number of pacemaker im-
plants (6).
In describing the epidemiology of SSS, Jensen et
al. (7) in this issue of the Journal conrmed that SSS
was associated with the increasing age of the popu-
lation, predicted to produce a steady increase in the
incidence of SSS and, thus, in the need for permanent
pacemaker implantation, estimating that by 2060,
there will be more than 170,000 new cases of SSS
per year.
SEE PAGE 531
The investigators of this study identied SSS
by the International Classication of Disease-revision
9-Clinical Modication (ICD-9-CM) code 427.81,
which incorporates SSS, sinoatrial node dysfunction,
tachycardia-bradycardia syndrome, and persistent
sinus bradycardia. They considered SSS to be pre-
sent if the medical record included a diagnosis of
SSS and symptoms or signs consistent with SSS
 540 Ewy JACC VOL. 64, NO. 6, 2014

Sick Sinus Syndrome: Synopsis AUGUST 12, 2014:53940

(e.g., syncope, dizziness, bradycardia, sinus pauses),
with no evidence of other conditions responsible for
the episode, such as atrioventricular block or medi-
cation use (7). These investigators conrmed that the
incidence of SSS increased with age, but found that
blacks had a lower risk than whites. They reported
that the incidence of SSS was associated with greater
body mass index, greater height, longer QRS interval,
lower heart rate, and prevalent hypertension, right
bundle branch block, and cardiovascular disease (7).
The SSS may be difcult to diagnosis, because
initially, the symptoms may be mild and very inter-
mittent. When the patient presents with symptoms
consistent with SSS, a detailed history of medica-
tions, including alternative medications, is essential.
In addition, it is rare, but the patient may be taking
the same medication prescribed by 2 different phy-
sicians: one by a generic name and the other by a
trade name, such as metoprolol and Toprol-XL, or
digoxin and Lanoxin, where known side effects of
overdose are arrhythmias consistent with SSS.
The physical examination and the electrocardio-
gram are important, including performing carotid si-
nus pressure, while observing the electrocardiogram.
An asystole response of 3 or more seconds to carotid
sinus pressure is strongly suggestive of SSS and an
indication for a permanent pacemaker if the patient
has a history of syncope (8).
The denitive diagnosis is often made by ambu-
latory monitoring or by electrophysiological studies.
Modern ambulatory monitoring alternatives are often
essential to this diagnosis. The increasing sophisti-
cation, diagnostic ability, and surgical skills of the
modern electrophysiologists make the diagnosis easy
and therapy of patients with SSS effective. Jensen
et al. (7) predict that with the aging of our population,
SSS will be a major factor in increasing the need for
permanent pacemakers. This fact will drive research
into more effective approaches to the diagnosis of
the SSS and into decreasing the size and type of
permanent pacemakers, as well as increasing the
sophistication of future permanent pacemakers.
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
Gordon A. Ewy, Department of Medicine, University
of Arizona Sarver Heart Center, 932 West San Martin
Drive, Tucson, Arizona 85704. E-mail: gaewy1933@
gmail.com.

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