Inappropriate sinus tachycardia

Last updated
Inappropriate sinus tachycardia
Other namesIST
ECG Sinus Tachycardia 132 bpm.jpg
ECG of 33-year-old female showing sinus tachycardia at 132 bpm
Specialty Cardiology
Symptoms Palpitations, Chest pain, Fatigue, shortness of breath, Lightheadedness, and syncope. [1]
CausesIncreased sympathetic or decreased parasympathetic drive, increased intrinsic heart rate, dysfunctional neurohormonal modulation, ectopic sinus node activity, and beta-adrenergic receptor autoantibodies.
Diagnostic method Persistent or recurrent sinus tachycardia on a 12-lead electrogram or long-term monitoring that is not explained by other means
Differential diagnosis Metabolic myopathies, Postural orthostatic tachycardia syndrome, Sinus node reentry, and Vasovagal syncope.
TreatmentMedications, lifestyle modifications, surgical sinus node exclusion, and sinus or AV node radiofrequency catheter ablation.
Medication Ivabradine and beta-blockers.
Frequency1.16% in the general population

Inappropriate sinus tachycardia (IST) is defined as sinus tachycardia that is not caused by identifiable medical ailments, a physiological reaction, or pharmaceuticals (a diagnosis of exclusion) and is accompanied by symptoms, frequently invalidating and affecting quality of life. [2] IST symptoms include palpitations, chest discomfort, exhaustion, shortness of breath, presyncope, and syncope. [1]

Contents

While sinus tachycardia is very common and is the most common type of tachycardia, it is rare to be diagnosed with inappropriate sinus tachycardia as an independent symptom that is not part of a larger condition. Although somewhat rarely diagnosed, IST is viewed by most to be a benign condition in the long-term. Symptoms of IST, however, may be distracting and warrant treatment. The heart is a strong muscle and typically can sustain the higher-than-normal heart rhythm, though monitoring the condition is generally recommended. [3] The mechanism and primary etiology of inappropriate sinus tachycardia has not been fully elucidated. An autoimmune mechanism has been suggested, as several studies have detected autoantibodies that activate beta adrenoreceptors in some patients. [4] [5] The mechanism of the arrhythmia primarily involves the sinus node and peri-nodal tissue [6] and does not require the AV node for maintenance. Treatments in the form of pharmacological therapy or catheter ablation are available, but the condition is currently difficult to treat successfully.

Signs and symptoms

Palpitations are the most common symptom in roughly 90% of patients. Other symptoms include chest pain, fatigue, shortness of breath, presyncope, syncope, [1] reduced exercise tolerance, anxiety, panic attacks, and headaches. These symptoms are usually associated with an elevated heart rate. While some patients have persistently elevated sinus rates, others have paroxysmal episodes with normal heart rates in between. [7]

Causes

The exact cause of Inappropriate sinus tachycardia is still being debated and remains unknown. Several mechanisms have been suggested, including increased sympathetic or decreased parasympathetic drive, increased intrinsic heart rate, dysfunctional neurohormonal modulation, ectopic sinus node activity, and beta-adrenergic receptor autoantibodies. Some data show an abnormal response to autonomic stimulation as a result of tissue/cell level changes (intrinsic mechanism), whereas others show a disruption of the autonomic stimulation itself with normal tissues/cell level findings (extrinsic mechanism). It is possible that both mechanistic theories are correct because, despite sharing a single common pathway of sinus tachycardia, individual patients' underlying mechanistic etiologies may differ. [8]

Mechanism

Over 15 electrical currents tightly control the sinus node. The calcium clock and the funny current appear to be the most important currents in regulating sinus node rate. Sinus activation and thus heart rate is regulated further through the autonomic nervous system. At rest, the sinus node is primarily regulated by tonic and phasic parasympathetic activation in normal, healthy individuals. Exercise causes vagal activation, sympathetic activation, and increases in catecholamine levels, which raises sinus rates. [3] [9] Any aspect of regular regulatory processes influencing sinus rate may be compromised in patients with IST. [3]

Diagnosis

Inappropriate sinus tachycardia is diagnosed when there is persistent or recurrent sinus tachycardia on a 12-lead electrogram or long-term monitoring that is not explained by other means. Invasive testing, such as electrophysiology studies, are not helpful in making the diagnosis, but they may be useful in ruling out a concomitant supraventricular tachycardia mechanism. [3] Inappropriate sinus tachycardia is a diagnosis of exclusion that is rarely made in an asymptomatic patient. [2]

The following criteria are commonly used to define inappropriate sinus tachycardia: [10]

  1. The axis and morphology of the P wave during tachycardia similar to or identical to that experienced during sinus rhythm
  2. A resting heart rate of 100 beats per minute or an increase in heart rate of 100 beats per minute with minimal exertion
  3. Excluding any potential secondary causes of sinus tachycardia
  4. Ruling out atrial tachycardias
  5. Palpitations or presyncope (or both) symptoms that have been clearly linked to resting or easily induced sinus tachycardia.

Secondary causes of sinus tachycardia must be ruled out and corrected if present. A full endocrinology evaluation for disease entities such as hyperthyroidism, pheochromocytoma, and diabetes mellitus with evidence of autonomic dysfunction should be included in the evaluation for inappropriate sinus tachycardia. [10]

Differential diagnosis

Inappropriate sinus tachycardia is primarily a diagnosis of exclusion. [7] Upon exertion, an inappropriate heart rate response of sinus tachycardia can be seen in some inborn errors of metabolism that result in metabolic myopathies, such as McArdle disease (GSD-V) [11] [12] and hereditary myopathy with lactic acidosis (Larsson–Linderholm syndrome). [13] [14]

Sinus tachycardia is a feature of both postural orthostatic tachycardia syndrome and Inappropriate sinus tachycardia. In POTS, there's an abnormal response by the autonomic nervous system when standing up. POTS symptoms are most common when the patient is upright. POTS syndromes and inappropriate sinus tachycardia may overlap, raising the possibility of shared mechanisms. The most common symptoms of POTS are dizziness and, on occasion, syncope, which are also common in IST. [2]

Sinus node reentry is another differential diagnosis for Inappropriate sinus tachycardia. An ectopic atrial rhythm occurring near the sinus node may also mimic Inappropriate sinus tachycardia. Syncope or pre-syncope may occur in IST patients and be the dominant symptom, with associated prodromal symptoms such as diaphoresis and visual blurring, leading to the diagnosis of vasovagal syncope and the diagnosis of IST being overlooked. [2]

Treatment

Inappropriate sinus tachycardia is a chronic medical condition that has a negative impact on one's quality of life. There are numerous treatment options available, which are frequently combined with nonpharmacologic lifestyle and dietary changes. It is frequently advised to avoid triggers or stimulants such as caffeine, nicotine, and alcohol. [7]

Managing inappropriate sinus tachycardia, controlling symptoms and decreasing rate, remains a significant challenge, especially given the ambiguity of the syndrome itself. Controlling the heart rate, on the other hand, does not always result in the elimination of symptoms. Controlling sinus rate in asymptomatic IST patients is debatable given that the treatment may be worse than the syndrome itself. In IST, no single therapy completely and effectively reduces heart rate and symptoms, which is likely due to the problem's complexity and a lack of a complete understanding of the causes. [3]

In most patients, sleeping with the head of the bed elevated and increasing plasma volume through generous salt and fluid intake can be beneficial with minimal risk. In patients with venous pooling, compression stockings can offer additional benefits; however, adherence often becomes an issue. These lifestyle changes may alleviate symptoms and prevent reflex tachycardia, which is especially common in chronic dehydration. In patients with overt psychosomatic complaints, it is acceptable to consider a psychiatric evaluation. [15]

Pharmacologic therapy for Inappropriate sinus tachycardia patients should be started gradually, with the goal of lowering HR and improving symptoms. The pharmacologic treatment of IST is empirical, with a trial-and-error approach typically employed. [15]

Beta blockers are the first-line treatment for inappropriate sinus tachycardia. β-blockers, in general, alleviate symptoms. Patients with β-adrenergic receptor sensitivity and elevated catecholamine levels throughout orthostatic stress usually respond well to a variety of β-blockers. Nondihydropyridine calcium channel blockers have demonstrated a modest benefit in symptom control of IST in patients with contraindications to β-blockers. [15]

Other drugs, such as sympatholytics and cholinesterase inhibitors like pyridostigmine, have very limited clinical evidence. There have been no randomized controlled trials regarding the use of these drugs in the treatment of Inappropriate sinus tachycardia, and all, with the possible exception of β-blockers, should be considered off-label indications. [15]

Ivabradine has been shown to reduce HR, improve exercise capacity quantitatively, and reduce subjective symptom burden. The drug appears to have a lower proarrhythmic risk and is well tolerated. Ivabradine shows great promise as the possible therapy of choice for beta-blocker intolerant or suboptimally responsive patients with a chronic condition that frequently becomes clinically problematic in management. [16]

There are no specific guidelines in place to determine which patients with inappropriate sinus tachycardia should be considered for invasive treatments. Interventions to treat inappropriate sinus tachycardia range from surgical sinus node exclusion to sinus or AV node radiofrequency catheter ablation, which typically is followed by permanent pacemaker implantation and, in recent years, radiofrequency sinus node modification. [17]

Several clinical trials have described sinus node modification or ablation in Inappropriate sinus tachycardia. Primary success rates are generally good, however, there is a high rate of symptom recurrence and significant complication rates. These complications include the need for permanent pacing, transient superior vena cava syndrome, and temporary or permanent paralysis of the phrenic nerve. Furthermore, sinus node modification or ablation may not alleviate all IST-related symptoms. There is also no consensus on the best approach, which includes modifications or ablation, open chest versus conventional intravascular access, and mapping methods. Finally, there has been no evidence of symptomatic improvement over time. [18]

Outlook

IST has a generally benign prognosis. One possible reason for a favourable prognosis is that, while IST patients have faster heart rates, their heart rate slows slightly during sleep as well as during various diurnal patterns. Long-term consequences are few, but published studies are small, follow-up is limited, and populations are varied. Although there have been isolated reports, IST is rarely associated with tachycardia-induced cardiomyopathy. [3] Symptoms may last for years but tend not to progress and may eventually fade away. [19]

Epidemiology

Inappropriate sinus tachycardia, defined as 24-hour average HR > 90 bpm and HR > 100 bpm in a supine or sitting position, has a prevalence of 1.16% in the general population. [20] The epidemiology of Inappropriate sinus tachycardia is not well understood. IST can occur at any age, but it is most common in adolescents and young adults. [2] Inappropriate sinus tachycardia was previously thought to be a rare condition affecting young women, with health professionals being overrepresented. This characterization may better define the group of IST patients who are most symptomatic and/or likely to seek medical attention, as opposed to the entire cohort of Inappropriate sinus tachycardia patients. [19]

In IST, the most common comorbidities are psychiatric, including a history of depression in 25.6% as well as anxiety in 24.6%. Higher rates of diabetes mellitus, hypertension, and hypothyroidism have been identified in those with IST, though lower rates of hyperthyroidism have been observed. 28.2% of patients reported an event or physical condition preceding the onset of IST symptoms. Pregnancy was the most common identifiable initiating factor in IST patients (7.9%). [21]

See also

Related Research Articles

<span class="mw-page-title-main">Bradycardia</span> Heart rate below the normal range

Bradycardia, also called bradyarrhythmia, is a resting heart rate under 60 beats per minute (BPM). While bradycardia can result from various pathologic processes, it is commonly a physiologic response to cardiovascular conditioning or due to asymptomatic type 1 atrioventricular block.

<span class="mw-page-title-main">Tachycardia</span> Heart rate exceeding normal resting rate

Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal or abnormal.

<span class="mw-page-title-main">Premature ventricular contraction</span> Skipped beat with ventricular origin

A premature ventricular contraction (PVC) is a common event where the heartbeat is initiated by Purkinje fibers in the ventricles rather than by the sinoatrial node. PVCs may cause no symptoms or may be perceived as a "skipped beat" or felt as palpitations in the chest. PVCs do not usually pose any danger.

<span class="mw-page-title-main">Wolff–Parkinson–White syndrome</span> Abnormal heart rhythm due to faulty electrical connections in the heart

Wolff–Parkinson–White syndrome (WPWS) is a disorder due to a specific type of problem with the electrical system of the heart involving an accessory pathway able to conduct electrical current between the atria and the ventricles, thus bypassing the atrioventricular node. About 60% of people with the electrical problem developed symptoms, which may include an abnormally fast heartbeat, palpitations, shortness of breath, lightheadedness, or syncope. Rarely, cardiac arrest may occur. The most common type of irregular heartbeat that occurs is known as paroxysmal supraventricular tachycardia.

<span class="mw-page-title-main">Sinus node dysfunction</span> Medical condition

Sinus node dysfunction (SND), also known as sick sinus syndrome (SSS), is a group of abnormal heart rhythms (arrhythmias) usually caused by a malfunction of the sinus node, the heart's primary pacemaker. Tachycardia-bradycardia syndrome is a variant of sick sinus syndrome in which the arrhythmia alternates between fast and slow heart rates.

<span class="mw-page-title-main">Supraventricular tachycardia</span> Abnormally fast heart rhythm

Supraventricular tachycardia (SVT) is an umbrella term for fast heart rhythms arising from the upper part of the heart. This is in contrast to the other group of fast heart rhythms – ventricular tachycardia, which start within the lower chambers of the heart. There are four main types of SVT: atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia (PSVT), and Wolff–Parkinson–White syndrome. The symptoms of SVT include palpitations, feeling of faintness, sweating, shortness of breath, and/or chest pain.

<span class="mw-page-title-main">AV nodal reentrant tachycardia</span> Medical condition

AV-nodal reentrant tachycardia (AVNRT) is a type of abnormal fast heart rhythm. It is a type of supraventricular tachycardia (SVT), meaning that it originates from a location within the heart above the bundle of His. AV nodal reentrant tachycardia is the most common regular supraventricular tachycardia. It is more common in women than men. The main symptom is palpitations. Treatment may be with specific physical maneuvers, medications, or, rarely, synchronized cardioversion. Frequent attacks may require radiofrequency ablation, in which the abnormally conducting tissue in the heart is destroyed.

<span class="mw-page-title-main">Postural orthostatic tachycardia syndrome</span> Abnormally high heart rate after a postural change

Postural orthostatic tachycardia syndrome (POTS) is a condition characterized by an abnormally large increase in heart rate upon sitting up or standing. POTS is a disorder of the autonomic nervous system that can lead to a variety of symptoms, including lightheadedness, brain fog, blurred vision, weakness, fatigue, headaches, heart palpitations, exercise intolerance, nausea, diminished concentration, tremulousness (shaking), syncope (fainting), coldness or pain in the extremities, numbness or tingling in the extremities, chest pain, and shortness of breath. Other conditions associated with POTS include myalgic encephalomyelitis/chronic fatigue syndrome, migraine headaches, Ehlers–Danlos syndrome, asthma, autoimmune disease, vasovagal syncope, and mast cell activation syndrome. POTS symptoms may be treated with lifestyle changes such as increasing fluid, electrolyte, and salt intake, wearing compression stockings, gentler and slow postural changes, avoiding prolonged bedrest, medication, and physical therapy.

<span class="mw-page-title-main">Catheter ablation</span> Removal or termination of an electrical pathway from parts of the heart

Catheter ablation is a procedure that uses radio-frequency energy or other sources to terminate or modify a faulty electrical pathway from sections of the heart of those who are prone to developing cardiac arrhythmias such as atrial fibrillation, atrial flutter and Wolff-Parkinson-White syndrome. If not controlled, such arrhythmias increase the risk of ventricular fibrillation and sudden cardiac arrest. The ablation procedure can be classified by energy source: radiofrequency ablation and cryoablation.

<span class="mw-page-title-main">Sinus bradycardia</span> Sinus rhythm with a rate that is lower than normal

Sinus bradycardia is a sinus rhythm with a reduced rate of electrical discharge from the sinoatrial node, resulting in a bradycardia, a heart rate that is lower than the normal range.

<span class="mw-page-title-main">Sinus tachycardia</span> Sinus rhythm with a rate that is higher than normal

Sinus tachycardia is a sinus rhythm of the heart, with an increased rate of electrical discharge from the sinoatrial node, resulting in a tachycardia, a heart rate that is higher than the upper limit of normal.

<span class="mw-page-title-main">Paroxysmal supraventricular tachycardia</span> Episodes of abnormally fast heart rhythm

Paroxysmal supraventricular tachycardia (PSVT) is a type of supraventricular tachycardia, named for its intermittent episodes of abrupt onset and termination. Often people have no symptoms. Otherwise symptoms may include palpitations, feeling lightheaded, sweating, shortness of breath, and chest pain.

Tachycardia-induced cardiomyopathy (TIC) is a disease where prolonged tachycardia or arrhythmia causes an impairment of the myocardium, which can result in heart failure. People with TIC may have symptoms associated with heart failure and/or symptoms related to the tachycardia or arrhythmia. Though atrial fibrillation is the most common cause of TIC, several tachycardias and arrhythmias have been associated with the disease.

Lown–Ganong–Levine syndrome (LGL) is a pre-excitation syndrome of the heart. Those with LGL syndrome have episodes of abnormal heart racing with a short PR interval and normal QRS complexes seen on their electrocardiogram when in a normal sinus rhythm. LGL syndrome was originally thought to be due to an abnormal electrical connection between the atria and the ventricles, but is now thought to be due to accelerated conduction through the atrioventricular node in the majority of cases. The syndrome is named after Bernard Lown, William Francis Ganong, Jr., and Samuel A. Levine.

<span class="mw-page-title-main">Ivabradine</span> Heart medication

Ivabradine, sold under the brand name Procoralan among others, is a medication, which is a pacemaker current (If) inhibitor, used for the symptomatic management of heart-related chest pain and heart failure. Patients who qualify for use of Ivabradine for coronary heart failure are patients who have symptomatic heart failure, with reduced ejection volume, and heart rate at least 70 bpm, and the condition not able to be fully managed by beta blockers.

<span class="mw-page-title-main">Syncope (medicine)</span> Transient loss of consciousness and postural tone

Syncope, commonly known as fainting or passing out, is a loss of consciousness and muscle strength characterized by a fast onset, short duration, and spontaneous recovery. It is caused by a decrease in blood flow to the brain, typically from low blood pressure. There are sometimes symptoms before the loss of consciousness such as lightheadedness, sweating, pale skin, blurred vision, nausea, vomiting, or feeling warm. Syncope may also be associated with a short episode of muscle twitching. Psychiatric causes can also be determined when a patient experiences fear, anxiety, or panic; particularly before a stressful event, usually medical in nature. When consciousness and muscle strength are not completely lost, it is called presyncope. It is recommended that presyncope be treated the same as syncope.

<span class="mw-page-title-main">Junctional ectopic tachycardia</span> Irregular heartbeat due to abnormal conduction from the atrioventricular nerve

Junctional ectopic tachycardia (JET) is a rare syndrome of the heart that manifests in patients recovering from heart surgery. It is characterized by cardiac arrhythmia, or irregular beating of the heart, caused by abnormal conduction from or through the atrioventricular node. In newborns and infants up to 6 weeks old, the disease may also be referred to as His bundle tachycardia or congenital JET.

Roemheld syndrome (RS), or gastrocardiac syndrome, or gastric cardiac syndrome or Roemheld–Techlenburg–Ceconi syndrome or gastric-cardia, was a medical syndrome first coined by Ludwig von Roemheld (1871–1938) describing a cluster of cardiovascular symptoms stimulated by gastrointestinal changes. Although it is currently considered an obsolete medical diagnosis, recent studies have described similar clinical presentations and highlighted potential underlying mechanisms.

<span class="mw-page-title-main">Arrhythmia</span> Group of medical conditions characterized by irregular heartbeat

Arrhythmias, also known as cardiac arrhythmias, are irregularities in the heartbeat, including when it is too fast or too slow. A resting heart rate that is too fast – above 100 beats per minute in adults – is called tachycardia, and a resting heart rate that is too slow – below 60 beats per minute – is called bradycardia. Some types of arrhythmias have no symptoms. Symptoms, when present, may include palpitations or feeling a pause between heartbeats. In more serious cases, there may be lightheadedness, passing out, shortness of breath, chest pain, or decreased level of consciousness. While most cases of arrhythmia are not serious, some predispose a person to complications such as stroke or heart failure. Others may result in sudden death.

<span class="mw-page-title-main">Automatic tachycardia</span> Medical condition

An automatic tachycardia is a cardiac arrhythmia which involves an area of the heart generating an abnormally fast rhythm, sometimes also called enhanced automaticity. These tachycardias, or fast heart rhythms, differ from reentrant tachycardias in which there is an abnormal electrical pathway which gives rise to the pathology. Most automatic tachycardias are supraventricular tachycardias (SVT). It is important to recognize an automatic tachycardia because the treatment will be different to that for a reentrant tachycardia. The most useful clue will be the presence of 'warm up' and 'cool down'. This means that whereas a reentrant tachycardia will both begin and end abruptly as cardiac conduction uses then ceases to use the accessory pathway, an automatic tachycardia will rise and fall gradually in rate as the automatic focus increases and decreases its automatic rate of electrical discharge.

References

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  14. ↑ Saltin, Bengt (2000). "Chapter 21: Circulatory Regulation in Muscle Disease". Exercise and Circulation in Health and Disease. Human Kinetics. pp. 271–279. ISBN   978-0-88011-632-9.
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  17. ↑ KRAHN, ANDREW D.; YEE, RAYMOND; KLEIN, GEORGE J.; MORILLO, CARLOS (1995). "Inappropriate Sinus Tachycardia: Evaluation and Therapy". Journal of Cardiovascular Electrophysiology. 6 (12). Wiley: 1124–1128. doi:10.1111/j.1540-8167.1995.tb00391.x. ISSN   1045-3873. PMID   8720214. S2CID   44516317 . Retrieved November 6, 2023.
  18. ↑ Sheldon, Robert S.; Grubb, Blair P.; Olshansky, Brian; Shen, Win-Kuang; Calkins, Hugh; Brignole, Michele; Raj, Satish R.; Krahn, Andrew D.; Morillo, Carlos A.; Stewart, Julian M.; Sutton, Richard; Sandroni, Paola; Friday, Karen J.; Hachul, Denise Tessariol; Cohen, Mitchell I.; Lau, Dennis H.; Mayuga, Kenneth A.; Moak, Jeffrey P.; Sandhu, Roopinder K.; Kanjwal, Khalil (2015). "2015 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Treatment of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia, and Vasovagal Syncope". Heart Rhythm. 12 (6). Elsevier BV: e41–e63. doi: 10.1016/j.hrthm.2015.03.029 . ISSN   1547-5271. PMC   5267948 . PMID   25980576 . Retrieved November 6, 2023.
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