Tachycardia-bradycardia syndrome: See “Subtypes and variants” for details.Alternative: phosphodiesterase inhibitors.First-line (after patient stabilization) : permanent pacemaker placement.Severe and/or frequent symptoms of bradycardia due to irreversible causes.See “ Management of unstable bradycardia” for initial management of SND causing hemodynamic compromise or severe symptoms. The long-term management of SND is detailed here. Oral theophylline challenge test: Consider prior to pacemaker insertion if a documented bradyarrhythmia and symptoms are both present but the correlation is uncertainĮlectrophysiology studies are not recommended in asymptomatic patients, as it is an invasive modality and the risks outweigh the potential benefits.Electrophysiology studies: may show prolonged sinus node recovery time in SND.Indications: diagnostic uncertainty in symptomatic patients.Suspected structural and/or infiltrative heart disease that cannot be confirmed with other diagnostic techniques: Consider advanced imaging.Concern for structural heart disease : transthoracic echocardiogram ( TTE).Sleep-related symptoms: Consider nocturnal polysomnography.Consider genetic testing (e.g., for SCN5A, HCN4 mutations) in consultation with a specialist.Seen in up to 50% of patients with SND Įvaluation for an underlying cause Laboratory studiesĮvaluate all patients for common reversible causes of SND as clinically indicated (i.e., based on history and physical examination).Heart rate does not increase sufficiently in response to increased activity or demand.Bradycardia alternating with intermittent atrial tachyarrhythmia.Isorhythmic dissociation: atria depolarization slower than ventricular depolarization.
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