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Heart Disease (Expert Forum)
Sick Sinus Syndrome...ALWAYS a pacemaker?
Answered by
Cleveland - OH
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Sick Sinus Syndrome...ALWAYS a pacemaker?
by Duffer1, Sep 01, 2005 12:00AM
Hi,
I am a 60 yr old female and recently had a cardiologist in a small town diagnose me with Sick Sinus Syndrome. (tachybrady subset) He immediately scheduled me for surgery to implant a dual chamber pacemaker. As I am uncomfortable having any procedure done without the benefit of a second opinion I made an appointment with an electrophysiologist at an excellent arrythmia clinic at an equally fine hospital in Philadelphia,600 miles from my home.
I was prepeared for the fact that I was being scheduled for a pacemaker when the EP shocked me with his opinion. Although he agreed that I was suffering from SSS and yes, I would eventually need a pacemaker,he felt at this time a PM wouldn't be necessary. My brady pauses on the Holter monitor were 3 seconds at the longest and I have not had any episodes of syncope. He explained that the prognosis for someone in my class would be the same as another in the same class who had the pacemaker.
I was relieved that he didn't feel that my condition, at this time, warranted a pacemaker but now I am thinking...do I need a tiebreaker? Does anyone ever get a THIRD opinion? (We women are never satisfied!)
I was told to return when the symptoms became worse, and he explained that they would, but he assured me that he didn't feel that I would walk outside and fall over dead from it.
Now I am confused. I do trust the EP's opinion as he is the expert on PMs. My question is: Does SSS always require a PM when diagnosed? Thanks very much for your insight. LM
I am a 60 yr old female and recently had a cardiologist in a small town diagnose me with Sick Sinus Syndrome. (tachybrady subset) He immediately scheduled me for surgery to implant a dual chamber pacemaker. As I am uncomfortable having any procedure done without the benefit of a second opinion I made an appointment with an electrophysiologist at an excellent arrythmia clinic at an equally fine hospital in Philadelphia,600 miles from my home.
I was prepeared for the fact that I was being scheduled for a pacemaker when the EP shocked me with his opinion. Although he agreed that I was suffering from SSS and yes, I would eventually need a pacemaker,he felt at this time a PM wouldn't be necessary. My brady pauses on the Holter monitor were 3 seconds at the longest and I have not had any episodes of syncope. He explained that the prognosis for someone in my class would be the same as another in the same class who had the pacemaker.
I was relieved that he didn't feel that my condition, at this time, warranted a pacemaker but now I am thinking...do I need a tiebreaker? Does anyone ever get a THIRD opinion? (We women are never satisfied!)
I was told to return when the symptoms became worse, and he explained that they would, but he assured me that he didn't feel that I would walk outside and fall over dead from it.
Now I am confused. I do trust the EP's opinion as he is the expert on PMs. My question is: Does SSS always require a PM when diagnosed? Thanks very much for your insight. LM
Doctor's Answer
by Cleveland Clinic, Sep 01, 2005 12:00AM
, Sep 01, 2005 12:00AM
Duffer,
There are specific guidelines that the American Heart Association and American College of Cardiology specify for who might benefit or recieve harm from particular treatments. I've included them brlow and you can find the whole recommendations online at
http://www.acc.org/clinical/guidelines/april98/dirindex.htm
The most important factor is the presence of symptoms (class 1), beyond that there are some loose guidelines for those that might benefit (class II), and some where there are no benefit (class 3). Hope this helps. Good luck
Indications for Permanent Pacemaker Implantation in Sick Sinus Syndrome
Class I*
1.SSS with documented symptomatic bradycardia, including frequent sinus pauses that produce symptoms. In some patients, bradycardia is iatrogenic and will occur as a consequence of essential long-term drug therapy of a type and dosage for which there are no acceptable alternatives.
2.Symptomatic chronotropic incompetence
Class IIa
1.SSS occurring spontaneously or as a result of necessary drug therapy, with heart rate less than 40 bpm when a clear association between significant symptoms consistent with bradycardia and the actual presence of bradycardia has not been documented.
Class IIb
1.In minimally symptomatic patients, chronic heart rate less than 30 bpm while awake
Class III
1.SSS in asymptomatic patients, including those in whom substantial sinus bradycardia (heart rate less than 40 bpm) is a consequence of long-term drug treatment
2.SSS in patients with symptoms suggestive of bradycardia that are clearly documented as not associated with a slow heart rate
3.SSS with symptomatic bradycardia caused by nonessential drug therapy
There are specific guidelines that the American Heart Association and American College of Cardiology specify for who might benefit or recieve harm from particular treatments. I've included them brlow and you can find the whole recommendations online at
http://www.acc.org/clinical/guidelines/april98/dirindex.htm
The most important factor is the presence of symptoms (class 1), beyond that there are some loose guidelines for those that might benefit (class II), and some where there are no benefit (class 3). Hope this helps. Good luck
Indications for Permanent Pacemaker Implantation in Sick Sinus Syndrome
Class I*
1.SSS with documented symptomatic bradycardia, including frequent sinus pauses that produce symptoms. In some patients, bradycardia is iatrogenic and will occur as a consequence of essential long-term drug therapy of a type and dosage for which there are no acceptable alternatives.
2.Symptomatic chronotropic incompetence
Class IIa
1.SSS occurring spontaneously or as a result of necessary drug therapy, with heart rate less than 40 bpm when a clear association between significant symptoms consistent with bradycardia and the actual presence of bradycardia has not been documented.
Class IIb
1.In minimally symptomatic patients, chronic heart rate less than 30 bpm while awake
Class III
1.SSS in asymptomatic patients, including those in whom substantial sinus bradycardia (heart rate less than 40 bpm) is a consequence of long-term drug treatment
2.SSS in patients with symptoms suggestive of bradycardia that are clearly documented as not associated with a slow heart rate
3.SSS with symptomatic bradycardia caused by nonessential drug therapy
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It won't help to stay up all night! And be ready with your question when you do start trying. Some people type it out in Word first at their leisure, then copy and paste it to save time if you get on unexpectedly. There is a character limit so be precise as possible.
Good luck!
Also to the person that posted, a third opinion is like rubber match between sports competitors, but sometimes it helps you with your decision , personally in your case I would probably takes the EP docs advice. Good luck.
I have sick sinus syndrome but had a pulse rate in the upper thirties and forties so got a pacemaker. At a setting of 79, I was paced at lest half of the time. Since you only got one EP opinion, a second one would not be a bad idea. My cardiologist worked very closely with an excellent EP for my situation. I have since that time had a host of other problems that resulted in multiple cardioverions, AV ablation, heart failure, heart surgery and now I have a BI-V pacer and ICD and am 100% paced. I am please to say that I am doing well considering....take many more drugs than I would like...but they keep saying to me...the alternative would not be so good!!
My pulse rate is normally about 85. I have no problems doing normal activites and have no shortness of breath walking up stairs etc. During monitoring with the Holter monitor my BPM went down to 30 during sleep and my pauses were 2.8 to 3 seconds. Remember that I have the tachybrady subset also and that means my heart goes too slow AND too fast, the more severe (I have read) of the SSS. My pulse was also irregular; fast, slow, then pauses. I have never fainted but, from what I have read in the guidelines sent to me by the physician who answered my post, I am symptomatic and class 1, one who would benefit from a pacemaker. (that is, if chronotropic means 'affecting the rate of pulse'..LOL.. of course, I had to look that one up.) The EP put me in class 2 and, from what I know about my symptoms, therein lies the confusion. Perhaps because I am not dizzy and have never fainted? I have no idea.
My SSS is also not caused (I think) by any drugs prescribed as there was a list in the guidelines and I have never taken any of them. Back again in Class 1. I have no idea if it could be caused by underlying disease as I was not tested for anything other than heart and my echo and stress test were fine.
My cardiologist was working with no one. He just scheduled me for a pacemaker and when I asked if he had conferred with the 5 other physicians in his practice he said to me, "Why should I? I'm a board certified cardiologist." I got the second opinion on my own as the thought of a pacemaker scared me and I felt that if he had the opportunity to tap into the minds of five other physicians then that would have been enough opinions for me. He didn't agree that I needed an EP either.
I have to trust someone and I sought out the EP for his opinion so yes, I guess I'll just take it and call him again when this disease progresses, as he says it will.
If you read this, thank you doctor for your answer. I do appreciate it. Thanks, too, to everyone who posted.
By the way, I posted my question about 10AM EST so it appears that mid morning is working for this time zone anyway.
As an aside, I have sleep apnea, have had it for quite some time but I just found out after being tested twice. I was wishing, hoping, praying that this was all a mistake and that the brady and pauses were from my sleep apnea. No such luck though.
Life's short..I guess I'll eat dessert first from now on. Duffer
This forum is wonderful, a great service. Thanks again. Duffer