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Heart Disease (Expert Forum)
Re: Sinus Tachycardia
This forum is for questions and support regarding heart issues such as: Angina, Angioplasty, Arrhythmia, Bypass Surgery, Cardiomyopathy, Coronary Artery Disease, Defibrillator, Heart Attack, Heart Disease, High Blood Pressure, Mitral Valve Prolapse, Pacemaker, PAD, Stenosis, Stress Tests.
Re: Sinus Tachycardia
by Denise__0__0, Jan 01, 1995 12:00AM
Posted By Denise on December 06, 1998 at 18:59:24:
In Reply to: Sinus Tachycardia posted by Allison on December 06, 1998 at 16:49:35:
I read with interest a letter posted on Apr 16, 1998, by a father whose daughter was diagnosed with sinus tachycardia. I, too, was diagnosed at age 30 with sinus tach. However, I've been tested for hyperthyroidism and I've seen a cardiologist with no additional diagnosis. I am in the Army and have been running for over 8 years, so I'm not out of shape. My heart rate gets above 180 and usually above 190 every time I run. Afterwards, my HR takes about 30 minutes to drop below 140 and another two hours to go below 120. My HR even goes above 100-110 when I climb one flight of stairs.
These symptoms do not cause me problems in most areas of my life except when it comes to improving my running times. In the Army, running is very important, especially for an officer (I'm a CPT). I am unable to improve much because I am basically running a sprint (as far as my heart is concerned) every time I run. I can't believe this is normal. Even if I run really slow to keep my HR low, it climbs slowly during the run until it exceeds 180 after about two miles.
I have had a 24-hr Holter monitor and a stress test. Unfortunately, these were all evaluated by an Army internal medicine doctor who, after the tests, said I was in excellent shape and that it is very normal for well-conditioned athletes to have high heart rates. I know this isn't true so it was difficult to accept any evaluation from him. I saw a civilian cardiologist soon after who basically said that he's never seen this condition in someone who was in shape, but he couldn't find anything wrong. Of course, all he did was listen to my heart; no additional tests were done and he didn't have the complete results of the Holter monitor.
Is there any advice you can give me? I am moving to Korea in two more weeks where I will be taking command of a company. During company command my running ability will tested constantly. I need to conquer this whether through training or medication (preferably training). I will only have Army doctors available in Korea and, most likely, none of them will be cardiologists. However, if I can guide them down some likely paths toward finding a diagnosis/treatment, it will help.
*****************
Hi Allison,
I too have Sinus Tachycardia, but mine is "inappropriate sinus tachycardia", which was diagnosed after Radio Frequency Ablation. I had an ablation done for PSVT and the inappropriate sinus tachycardia was noticed then too. Actually, they knew I had sinus tachycardia before the ablation, but just confirmed it. Anyways, I have posted questions about the Sinus Tachycardia and Dr. CRC (wonderful source of information) had attached this to my response. I notice s/he attached this to a few people inquiring about Sinus Tachycardia. I'm sure they will give you an answer soon, but here is just a little to read FYI.
Sometimes Sinus Tachycardia is just one of those unknown things. I take Tenormin (beta-blocker) to help with mine because I (and electrophysiologist) didn't want my Sinus Node modified. From reading this forum, I definitely don't feel alone! Good luck Allison and I hope you have a great time in Korea :-)
Here is what Dr. CRC attaches:
Thank you for your question. As you can see by scrolling through this site we get many questions regarding
tachycardia and palpitations. There are many causes of tachycardia and they can be divided roughly into sinus
(originating from the sinus node or heart's natural pacemaker) and non-sinus tachycardias. Nonsinus tachycardias are
either supraventricular (coming from the upper chambers of the heart) or ventricular (coming from the lower chambers
of the heart). Supraventricular tachycardias include: paroxysmal supraventricular tachycardia, atrial flutter, atrial
fibrillation and AV nodal tachycardia. Ventricular tachycardias are more serious in nature and are due to a rapid
depolarization of the ventricles.
Sinus tachycardia is defined as a heart rate of greater than 100 beats per minute originating from the sinus node. Sinus
tachycardia is classified as either appropriate or inappropriate. There are many causes of appropriate sinus tachycardia
such as exercise, anxiety, panic attacks, dehydration, deconditioning, volume loss due to bleeding or other loss of
body fluids, hyperthyroidism, electrolyte abnormalities and many other conditions.
Inappropriate sinus tachycardia can only be diagnosed when all causes of appropriate sinus tachycardia have been ruled
out. It is not clear what causes inappropriate sinus tachycardia but possible etiologies are an increase in the rate at which
the sinus node depolarizes and an increased sensitivity to adrenaline. Once the diagnosis has been made by ruling out
all of the potential causes of appropriate sinus tachycardia there are several treatment options. If the symptoms are not
overly concerning no treatment needs to be done. There is no increase in morbidity or mortality in persons with this
condition and they can expect to have a normal life-span. For persons in whom the symptoms are unbearable
medications such as beta blockers or calcium channel blockers can be used, usually with good results. In the rare
person unable to tolerate medical treatment catheter ablation (burning) of the sinus node with insertion of a pacemaker
or surgical removal of the sinus node have been used in the past. Newer techniques are being developed using catheter
ablation to modify and not destroy the sinus node thus avoiding the need for a pacemaker. This procedure is still in it's
infancy and should only be undertaken at a major medical center after consultation with an electrophysiologist.
Below are some journal articles that address this topic in depth. Your local medical library should be able to help you
find copies.
Review Articles:
Krahn AD. Yee R. Klein GJ. Morillo C. Inappropriate sinus tachycardia: evaluation and therapy. Journal of
Cardiovascular Electrophysiology. 6(12):1124-8, 1995 Dec.
Abstract
Inappropriate sinus tachycardia is an ill-defined clinical syndrome characterized by an increased resting heart rate
accompanied by an exaggerated response to exercise or stress. It is not associated with underlying structural heart
disease. The mechanism may involve a primary abnormality of the sinus node demonstrating enhanced automaticity or,
alternatively, a primary autonomic disturbance with increase sympathetic activity and enhanced sinus node
beta-adrenergic sensitivity. The diagnosis of inappropriate sinus tachycardia is one of exclusion. It is most common in
young females, with a disproportionate number employed in the health care field. Autonomic and electrophysiologic
testing may be required in selected individuals to clarify the mechanism and rule out sinus node reentry or right atrial
tachycardia. Therapy of inappropriate sinus tachycardia is empiric. Pharmacologic approaches include beta blockers or
verapamil. Radiofrequency catheter ablation of the superior portion of the sinus node shows promise as a useful
alternative in patients with refractory symptoms.
Sims JM. Miracle V. Sinus tachycardia. Nursing. 26(6):49, 1996 Jun.
Articles Concerning Catheter Treatment Options.
Lee RJ. Kalman JM. Fitzpatrick AP. Epstein LM. Fisher WG. Olgin JE. Lesh MD. Scheinman MM. Radiofrequency
catheter modification of the sinus node for "inappropriate" sinus tachycardia. Circulation. 92(10):2919-28, 1995 Nov
15.
BACKGROUND: Radiofrequency catheter ablation is the treatment of choice for patients with paroxysmal
supraventricular tachycardias refractory to medical therapy. However, in symptomatic patients with inappropriate sinus
tachycardia resistant to drug therapy, catheter ablation of the His' bundle with permanent pacemaker insertion is
currently applied. We evaluated the safety and efficacy of radiofrequency modification of the sinus node as alternative
therapy for patients with inappropriate sinus tachycardia. METHODS AND RESULTS: Sixteen patients with disabling
episodes of inappropriate sinus tachycardia refractory to drug therapy (4.2 +/- 0.3 drug trials) underwent either total
sinus node ablation or sinus node modification. The region of the sinus node was identified as the region of earliest
atrial activation in sinus rhythm during electrophysiological study. This region was further defined by use of
intracardiac echocardiography (ICE) in 9 patients, in whom it was found that an ablation catheter could be guided
reliably and maintained on the crista terminalis. Radiofrequency energy was delivered during tachycardia between either
a standard 4-mm or custom 10-mm thermistor-imbedded catheter tip and a skin patch. Total sinus node ablation was
performed successfully in all 4 patients in whom it was attempted and was characterized by a junctional escape rhythm.
Sinus node modification was successfully achieved in all 12 patients in whom it was attempted and was characterized
by a 25% reduction in the sinus heart rate. For the group as a whole, exercise stress testing after ablation revealed a
gradual chronotropic response, with a significant reduction in maximal heart rate (132.8 +/- 6.5 versus 179.5 +/- 3.6
beats per minute [bpm]; P < .001) without evidence of an exaggerated heart rate response to a light workload (103.0
+/- 4.1 versus 139.5 +/- 3.5 bpm; P < .001). Twenty-four-hour ambulatory ECG monitoring revealed a significant
decrease in maximal heart rate and mean heart rate after ablation (167.2 +/- 2.6 versus 96.7 +/- 5.0 bpm, P < .001, and
125.6 +/- 5.0 versus 54.1 +/- 5.3 bpm, P < .001, respectively). There was a significant decrease in the number of
applications of radiofrequency energy required in patients undergoing modification of the sinus node when guided by
ICE compared with fluoroscopy alone (3.6 +/- 0.8 versus 10.4 +/- 2.1; P < .01) as well as a decrease in fluoroscopy
time (33.0 +/- 9.5 versus 58.5 +/- 8.4 minutes). After a mean follow-up period of 20.5 +/- 0.3 months, there were no
recurrences of inappropriate sinus tachycardia in patients who underwent a total sinus node ablation. However, 2
patients who had a total sinus node ablation subsequently required permanent pacing because of symptomatic pauses,
and 1 patient developed an ectopic atrial tachycardia. After a mean follow-up of 7.1 +/- 1.7 months, there were two
recurrences of inappropriate sinus tachycardia in patients who underwent sinus node modification. However, no
significant bradycardia or pauses were observed. Complications encountered during the study included 1 patient who
developed transient right diaphragmatic paralysis and another patient who developed transient superior vena cava
syndrome. CONCLUSIONS: Sinus node modification is feasible in humans and should be considered as an alternative
to complete atrioventricular junctional ablation for patients with disabling inappropriate sinus tachycardia refractory to
medical management. Sinus node modification may be aided by ICE.
Jayaprakash S. Sparks PB. Vohra J. Inappropriate sinus tachycardia (IST): management by radiofrequency
modification of sinus node. Australian & New Zealand Journal of Medicine. 27(4):391-7, 1997 Aug.
BACKGROUND: Inappropriate sinus tachycardia (IST) is a rare form of supraventricular arrhythmia. It can cause
disabling symptoms and may be refractory to medical treatment. In symptomatic drug refractory patients, sinus node
excision or total ablation of the sinus node with permanent pacemaker implantation was the only therapeutic option.
Recently, radiofrequency (RF) modification of the sinus node has been reported to be an effective treatment for this
condition. AIM: To present our experience with sinus node modification using RF energy in the management of IST.
METHODS: Between 1989 to 1996 three patients (two females and one male), aged 28-36 years were diagnosed with
symptomatic IST. All had failed multiple drugs and hence underwent sinus node modification using RF. In the first
two patients, the site of RF application was guided by anatomical landmarks using fluoroscopy to localise the presumed
most superior portion of the crista terminalis and also the earliest site of atrial activation. In the third patient, a 20 pole
electrode catheter was used to map the crista terminalis and guide the ablation. Success was defined by 20-30%
reduction in the heart rate with normal atrial activation sequence after ablation. RESULTS: The three patients described
here had IST by clinical, electrocardiographic and electrophysiological criteria and were refractory to multiple
antiarrhythmic drugs. The number of RF applications were 11, 15, and three applied at the site of earliest atrial
activation for the control of heart rates. Patient 3 had a early recurrence at one month and underwent repeat sinus node
modification (five RF applications). All three patients who underwent RF modification of the sinus node had a
successful outcome. The procedure was uncomplicated and the patients remain asymptomatic during follow up (20, 12
and three months) with satisfactory control of heart rate, although one patient requires atenolol which was previously
ineffective. CONCLUSIONS: RF modification of the sinus node is feasible and effective for IST, and should be the
treatment of choice in patients refractory to medical therapy.
Surgical treatment (Only as a last resort)
Esmailzadeh B. Bernat R. Winkler K. Meybehm M. Pfeiffer D. Kirchhoff PG. Surgical excision of the sinus node in a
patient with inappropriate sinus tachycardia. Journal of Thoracic & Cardiovascular Surgery. 114(5):861-4, 1997 Nov.
Information provided here is for general educational purposes only. Only your doctor can provide specific diagnoses
and treatments. If you would like to be seen at the Cleveland Clinic, please Call 1 - 800 - CCF - CARE for an
appointment at Desk F15 with a cardiologist
In Reply to: Sinus Tachycardia posted by Allison on December 06, 1998 at 16:49:35:
I read with interest a letter posted on Apr 16, 1998, by a father whose daughter was diagnosed with sinus tachycardia. I, too, was diagnosed at age 30 with sinus tach. However, I've been tested for hyperthyroidism and I've seen a cardiologist with no additional diagnosis. I am in the Army and have been running for over 8 years, so I'm not out of shape. My heart rate gets above 180 and usually above 190 every time I run. Afterwards, my HR takes about 30 minutes to drop below 140 and another two hours to go below 120. My HR even goes above 100-110 when I climb one flight of stairs.
These symptoms do not cause me problems in most areas of my life except when it comes to improving my running times. In the Army, running is very important, especially for an officer (I'm a CPT). I am unable to improve much because I am basically running a sprint (as far as my heart is concerned) every time I run. I can't believe this is normal. Even if I run really slow to keep my HR low, it climbs slowly during the run until it exceeds 180 after about two miles.
I have had a 24-hr Holter monitor and a stress test. Unfortunately, these were all evaluated by an Army internal medicine doctor who, after the tests, said I was in excellent shape and that it is very normal for well-conditioned athletes to have high heart rates. I know this isn't true so it was difficult to accept any evaluation from him. I saw a civilian cardiologist soon after who basically said that he's never seen this condition in someone who was in shape, but he couldn't find anything wrong. Of course, all he did was listen to my heart; no additional tests were done and he didn't have the complete results of the Holter monitor.
Is there any advice you can give me? I am moving to Korea in two more weeks where I will be taking command of a company. During company command my running ability will tested constantly. I need to conquer this whether through training or medication (preferably training). I will only have Army doctors available in Korea and, most likely, none of them will be cardiologists. However, if I can guide them down some likely paths toward finding a diagnosis/treatment, it will help.
*****************
Hi Allison,
I too have Sinus Tachycardia, but mine is "inappropriate sinus tachycardia", which was diagnosed after Radio Frequency Ablation. I had an ablation done for PSVT and the inappropriate sinus tachycardia was noticed then too. Actually, they knew I had sinus tachycardia before the ablation, but just confirmed it. Anyways, I have posted questions about the Sinus Tachycardia and Dr. CRC (wonderful source of information) had attached this to my response. I notice s/he attached this to a few people inquiring about Sinus Tachycardia. I'm sure they will give you an answer soon, but here is just a little to read FYI.
Sometimes Sinus Tachycardia is just one of those unknown things. I take Tenormin (beta-blocker) to help with mine because I (and electrophysiologist) didn't want my Sinus Node modified. From reading this forum, I definitely don't feel alone! Good luck Allison and I hope you have a great time in Korea :-)
Here is what Dr. CRC attaches:
Thank you for your question. As you can see by scrolling through this site we get many questions regarding
tachycardia and palpitations. There are many causes of tachycardia and they can be divided roughly into sinus
(originating from the sinus node or heart's natural pacemaker) and non-sinus tachycardias. Nonsinus tachycardias are
either supraventricular (coming from the upper chambers of the heart) or ventricular (coming from the lower chambers
of the heart). Supraventricular tachycardias include: paroxysmal supraventricular tachycardia, atrial flutter, atrial
fibrillation and AV nodal tachycardia. Ventricular tachycardias are more serious in nature and are due to a rapid
depolarization of the ventricles.
Sinus tachycardia is defined as a heart rate of greater than 100 beats per minute originating from the sinus node. Sinus
tachycardia is classified as either appropriate or inappropriate. There are many causes of appropriate sinus tachycardia
such as exercise, anxiety, panic attacks, dehydration, deconditioning, volume loss due to bleeding or other loss of
body fluids, hyperthyroidism, electrolyte abnormalities and many other conditions.
Inappropriate sinus tachycardia can only be diagnosed when all causes of appropriate sinus tachycardia have been ruled
out. It is not clear what causes inappropriate sinus tachycardia but possible etiologies are an increase in the rate at which
the sinus node depolarizes and an increased sensitivity to adrenaline. Once the diagnosis has been made by ruling out
all of the potential causes of appropriate sinus tachycardia there are several treatment options. If the symptoms are not
overly concerning no treatment needs to be done. There is no increase in morbidity or mortality in persons with this
condition and they can expect to have a normal life-span. For persons in whom the symptoms are unbearable
medications such as beta blockers or calcium channel blockers can be used, usually with good results. In the rare
person unable to tolerate medical treatment catheter ablation (burning) of the sinus node with insertion of a pacemaker
or surgical removal of the sinus node have been used in the past. Newer techniques are being developed using catheter
ablation to modify and not destroy the sinus node thus avoiding the need for a pacemaker. This procedure is still in it's
infancy and should only be undertaken at a major medical center after consultation with an electrophysiologist.
Below are some journal articles that address this topic in depth. Your local medical library should be able to help you
find copies.
Review Articles:
Krahn AD. Yee R. Klein GJ. Morillo C. Inappropriate sinus tachycardia: evaluation and therapy. Journal of
Cardiovascular Electrophysiology. 6(12):1124-8, 1995 Dec.
Abstract
Inappropriate sinus tachycardia is an ill-defined clinical syndrome characterized by an increased resting heart rate
accompanied by an exaggerated response to exercise or stress. It is not associated with underlying structural heart
disease. The mechanism may involve a primary abnormality of the sinus node demonstrating enhanced automaticity or,
alternatively, a primary autonomic disturbance with increase sympathetic activity and enhanced sinus node
beta-adrenergic sensitivity. The diagnosis of inappropriate sinus tachycardia is one of exclusion. It is most common in
young females, with a disproportionate number employed in the health care field. Autonomic and electrophysiologic
testing may be required in selected individuals to clarify the mechanism and rule out sinus node reentry or right atrial
tachycardia. Therapy of inappropriate sinus tachycardia is empiric. Pharmacologic approaches include beta blockers or
verapamil. Radiofrequency catheter ablation of the superior portion of the sinus node shows promise as a useful
alternative in patients with refractory symptoms.
Sims JM. Miracle V. Sinus tachycardia. Nursing. 26(6):49, 1996 Jun.
Articles Concerning Catheter Treatment Options.
Lee RJ. Kalman JM. Fitzpatrick AP. Epstein LM. Fisher WG. Olgin JE. Lesh MD. Scheinman MM. Radiofrequency
catheter modification of the sinus node for "inappropriate" sinus tachycardia. Circulation. 92(10):2919-28, 1995 Nov
15.
BACKGROUND: Radiofrequency catheter ablation is the treatment of choice for patients with paroxysmal
supraventricular tachycardias refractory to medical therapy. However, in symptomatic patients with inappropriate sinus
tachycardia resistant to drug therapy, catheter ablation of the His' bundle with permanent pacemaker insertion is
currently applied. We evaluated the safety and efficacy of radiofrequency modification of the sinus node as alternative
therapy for patients with inappropriate sinus tachycardia. METHODS AND RESULTS: Sixteen patients with disabling
episodes of inappropriate sinus tachycardia refractory to drug therapy (4.2 +/- 0.3 drug trials) underwent either total
sinus node ablation or sinus node modification. The region of the sinus node was identified as the region of earliest
atrial activation in sinus rhythm during electrophysiological study. This region was further defined by use of
intracardiac echocardiography (ICE) in 9 patients, in whom it was found that an ablation catheter could be guided
reliably and maintained on the crista terminalis. Radiofrequency energy was delivered during tachycardia between either
a standard 4-mm or custom 10-mm thermistor-imbedded catheter tip and a skin patch. Total sinus node ablation was
performed successfully in all 4 patients in whom it was attempted and was characterized by a junctional escape rhythm.
Sinus node modification was successfully achieved in all 12 patients in whom it was attempted and was characterized
by a 25% reduction in the sinus heart rate. For the group as a whole, exercise stress testing after ablation revealed a
gradual chronotropic response, with a significant reduction in maximal heart rate (132.8 +/- 6.5 versus 179.5 +/- 3.6
beats per minute [bpm]; P < .001) without evidence of an exaggerated heart rate response to a light workload (103.0
+/- 4.1 versus 139.5 +/- 3.5 bpm; P < .001). Twenty-four-hour ambulatory ECG monitoring revealed a significant
decrease in maximal heart rate and mean heart rate after ablation (167.2 +/- 2.6 versus 96.7 +/- 5.0 bpm, P < .001, and
125.6 +/- 5.0 versus 54.1 +/- 5.3 bpm, P < .001, respectively). There was a significant decrease in the number of
applications of radiofrequency energy required in patients undergoing modification of the sinus node when guided by
ICE compared with fluoroscopy alone (3.6 +/- 0.8 versus 10.4 +/- 2.1; P < .01) as well as a decrease in fluoroscopy
time (33.0 +/- 9.5 versus 58.5 +/- 8.4 minutes). After a mean follow-up period of 20.5 +/- 0.3 months, there were no
recurrences of inappropriate sinus tachycardia in patients who underwent a total sinus node ablation. However, 2
patients who had a total sinus node ablation subsequently required permanent pacing because of symptomatic pauses,
and 1 patient developed an ectopic atrial tachycardia. After a mean follow-up of 7.1 +/- 1.7 months, there were two
recurrences of inappropriate sinus tachycardia in patients who underwent sinus node modification. However, no
significant bradycardia or pauses were observed. Complications encountered during the study included 1 patient who
developed transient right diaphragmatic paralysis and another patient who developed transient superior vena cava
syndrome. CONCLUSIONS: Sinus node modification is feasible in humans and should be considered as an alternative
to complete atrioventricular junctional ablation for patients with disabling inappropriate sinus tachycardia refractory to
medical management. Sinus node modification may be aided by ICE.
Jayaprakash S. Sparks PB. Vohra J. Inappropriate sinus tachycardia (IST): management by radiofrequency
modification of sinus node. Australian & New Zealand Journal of Medicine. 27(4):391-7, 1997 Aug.
BACKGROUND: Inappropriate sinus tachycardia (IST) is a rare form of supraventricular arrhythmia. It can cause
disabling symptoms and may be refractory to medical treatment. In symptomatic drug refractory patients, sinus node
excision or total ablation of the sinus node with permanent pacemaker implantation was the only therapeutic option.
Recently, radiofrequency (RF) modification of the sinus node has been reported to be an effective treatment for this
condition. AIM: To present our experience with sinus node modification using RF energy in the management of IST.
METHODS: Between 1989 to 1996 three patients (two females and one male), aged 28-36 years were diagnosed with
symptomatic IST. All had failed multiple drugs and hence underwent sinus node modification using RF. In the first
two patients, the site of RF application was guided by anatomical landmarks using fluoroscopy to localise the presumed
most superior portion of the crista terminalis and also the earliest site of atrial activation. In the third patient, a 20 pole
electrode catheter was used to map the crista terminalis and guide the ablation. Success was defined by 20-30%
reduction in the heart rate with normal atrial activation sequence after ablation. RESULTS: The three patients described
here had IST by clinical, electrocardiographic and electrophysiological criteria and were refractory to multiple
antiarrhythmic drugs. The number of RF applications were 11, 15, and three applied at the site of earliest atrial
activation for the control of heart rates. Patient 3 had a early recurrence at one month and underwent repeat sinus node
modification (five RF applications). All three patients who underwent RF modification of the sinus node had a
successful outcome. The procedure was uncomplicated and the patients remain asymptomatic during follow up (20, 12
and three months) with satisfactory control of heart rate, although one patient requires atenolol which was previously
ineffective. CONCLUSIONS: RF modification of the sinus node is feasible and effective for IST, and should be the
treatment of choice in patients refractory to medical therapy.
Surgical treatment (Only as a last resort)
Esmailzadeh B. Bernat R. Winkler K. Meybehm M. Pfeiffer D. Kirchhoff PG. Surgical excision of the sinus node in a
patient with inappropriate sinus tachycardia. Journal of Thoracic & Cardiovascular Surgery. 114(5):861-4, 1997 Nov.
Information provided here is for general educational purposes only. Only your doctor can provide specific diagnoses
and treatments. If you would like to be seen at the Cleveland Clinic, please Call 1 - 800 - CCF - CARE for an
appointment at Desk F15 with a cardiologist
