Diagnosis Of Inappropriate Sinus Tachycardia Research Articles

Abstract 14607: Management of Inappropriate Sinus Tachycardia: A Promising Breakthrough

Introduction: Inappropriate Sinus Tachycardia (IST) is a cardiac dysautonomia with limited treatment options. This case highlights the effectiveness of a novel sinus node-sparing hybrid surgical ablation (SNSHA) for IST. Objective: To describe a novel hybrid surgical approach for management of IST. Case Description: A 43 y/o female presented with history of palpitations/tachycardia for 5 years. A comprehensive evaluation directed towards the diagnosis of IST with resting heart rates (HR) above 100 bpm and HR changes greater than 30% with minimal exertion. A trial of ivabradine & beta blockers along with lifestyle modifications offered limited relief. Patient was offered the novel SNSHA after a shared decision-making process. Methods: The SNSHA is a minimally invasive procedure performed by a CT surgeon in conjunction with an electrophysiologist involving thoracoscopic epicardial ablation of the sympathetic connections from the SVC to the IVC. The thoracoscopic approach allows for safeguarding of the phrenic nerve and sinus node followed by endocardial ablation along the lateral wall. Results: Intraprocedural pre and post ablation electroanatomic map (EAM) and electrogram (EGM) demonstrated an immediate drop in HR as shown in the Figure 1(a-d). An ILR was implanted during the procedure. On 45-day post-op visit, the patient experienced significant symptom relief and improvement in her HR as well as HR variability on ILR as shown in Figure 1(e). Conclusion: SNSHA offers a reasonable treatment option for patients with drug resistant IST. This procedure provided symptom alleviation and improvement in HR without increasing the risk of complications in comparison to sinus node modification ablation, which has previously been shown to be associated with higher incidence of pacemaker implantation.

Post-COVID-19 Inappropriate Sinus Tachycardia Treated with Naja tripudians: A Case Report

Abstract Background/Introduction The majority of people who recover from coronavirus disease 2019 (COVID-19) experience tachycardia and/or palpitations after slight activity or at rest. In some cases, the resting heart rate may remain above 100 beats per minute or get exacerbated out of proportion by slight activity. This persistent tachycardia appearing in post-COVID-19 may clinically present as inappropriate sinus tachycardia (IST). The common mode of diagnosis is electrocardiography after excluding other causes of tachycardia. So far, there is no reported study evaluating individualised homoeopathic intervention in post-COVID-19 IST in peer-reviewed homoeopathic journals. Method This report describes a case of tachycardia and palpitations developed after COVID-19. After complete evaluation of laboratory reports and clinical examination, the diagnosis of IST was made. After detailed case taking and repertorisation, Naja tripudians was prescribed as an individualised homoeopathic remedy to treat the case. Outcomes were assessed objectively on the basis of electrocardiography and subjectively using outcome related to impact on daily living (ORIDL) scale. Result There was a marked subjective improvement along with objective improvement as evidenced by electrocardiography images. The case showed a 4+ outcome on ORIDL scale. The Modified Naranjo Criteria total score was +9 out of a possible +13, providing definite evidence to attribute the clinical outcome with the homoeopathic intervention. Conclusion This single case demonstrates that Naja tripudians, a rarely used drug, may be helpful in treating post-COVID-19 IST. Clinical trials in this direction are required to conclude firm causal attribution.

Abstract 15694: Atrial Tachycardia Masquerading as Sinus Tachycardia - Electrophysiological Characteristics and Ablation Outcomes

Background: Focal atrial tachycardia (AT) is typically distinguished by P wave morphology and autonomic response. AT arising close to the sinus node can be easily misdiagnosed as Inappropriate sinus tachycardia (IST). Objective: This multicenter study sought to describe the electrophysiological (EP) features and ablation outcomes of perisinus node atrial tachycardia (PNAT). Methods: Baseline as well as procedural characteristics and outcome data of 7 patients with PNAT are described. Results: Mean age of the cohort was 38±17 years (100% female). Time from symptom onset to diagnosis was12.2± 9 months with an average of 1.7 prior hospitalizations. Mean baseline HR was127.8 bpm and all patients carried a diagnosis of IST. Baseline ECG in all patients was identical to sinus tachycardia, with exception of taller P waves in lead II in 5 patients and deeper negative component of P wave in V1. At EP study, mean AT cycle length was 420 msec and significant acceleration was seen with isoproterenol, mimicking IST. Activation mapping was done using Ensite TM Balloon Array (5), Precision TM (1) and Carto TM (1). Site of origin was slightly anterolateral to sinus node in 3 and anterior, inferior and medial to sinus node in 4 (Figure). AT was successfully ablated in all patients without any phrenic injury or sinus node dysfunction. Over 2.9 years of follow-up, only 1 patient had recurrence that was successfully re-ablated. Conclusion: PNAT has similar ECG and EP characteristics and is often misdiagnosed as IST. A high index of suspicion is needed for diagnosis. Evaluation of P wave morphology during tachycardia and careful activation mapping can enable successful ablation with excellent long-term outcomes.

LOOK CLOSELY AT THE P WAVE: INCESSANT ATRIAL TACHYCARDIA FROM THE LEFT ATRIAL APPENDAGE MISTAKEN FOR INAPPROPRIATE SINUS TACHYCARDIA

The diagnosis of inappropriate sinus tachycardia requires exclusion of both triggers of appropriate sinus tachycardia as well as other supraventricular tachycardia mechanisms. A 29 year-old male with treated Graves’ disease and palpitations was referred for inappropriate sinus tachycardia. He was

Pseudoaneurysm of thoracic aorta presenting as inappropriate sinus tachycardia: a case report

BackgroundPseudoaneurysm of thoracic aorta as a complication of blunt trauma to the chest, can present with a variety of symptoms due to mass compression effect. Here we report the first pseudoaneurysm of thoracic aorta presenting with chronic cough and inappropriate sinus tachycardia. The purpose of this case report is to highlight pseudoaneurysm of thoracic aorta as a rare differential diagnosis for inappropriate sinus tachycardia.Case presentationHere we report a case of 29-year-old white woman, a nurse, with history of a motor vehicle accident. She initially presented to medical attention with inappropriate sinus tachycardia 2 years following the motor vehicle accident during her pregnancy. Six years later she underwent sinoatrial node modification after failing a number of medications. Days prior to the ablation she developed a mild cough which became constant within a week following ablation. A computed tomography scan of her chest performed as part of a workup revealed an outpouching of the inferomedial aspect of the aortic arch, which was compressing her left main bronchus. She underwent arch repair surgery and recovered without complications. Four years later she presented with significant symptomatic sinus bradycardia requiring pacemaker placement.ConclusionsThis is the first reported case of thoracic pseudoaneurysm of aorta presenting with inappropriate sinus tachycardia due to compression of the vagal nerve and cough as a result of the left main bronchus compressive effect; it highlights the importance of considering structural abnormalities in a differential diagnosis of inappropriate sinus tachycardia before any interventions.

Inappropriate sinus tachycardia.

Inappropriate sinus tachycardia (IST) is a clinical syndrome, oftentimes debilitating, defined by fast sinus rates (>100 b.p.m. at rest or >90 b.p.m. on average over 24 h and not due to underlying causes) associated with symptoms that may include palpitations, as described in some guidelines and consensus documents. While heart rates may vary by patient, especially based upon gender and age, some individuals experience sinus tachycardia or persistent fast sinus rates with no symptoms; these individuals would not necessarily be considered to have the syndrome of IST. Various explanations for IST have been considered but a definitive common mechanism is not yet known; the true aetiology may be multifactorial. A thorough evaluation of secondary causes of tachycardia is required in the work-up of all cases and if found, must be treated before a diagnosis of IST can be made. Finally, effective treatments vary but can include ivabradine, beta-blockers, or calcium channel antagonists; ablation is seldom advised.

Taquicardia sinusal y taquicardia sinusal inapropiada

IntroductionSinus tachycardia is one of the most frequently encountered arrhythmias in clinical practice and its identification should place us on the trail of an intercurrent process in our patient, which may be benign (anxiety or painful) or life threatening (sepsis Severe or pulmonary thromboembolism, among others). On the other hand, inappropriate sinus tachycardia does not respond to a normal pathophysiological mechanism. DiagnosisThe diagnosis will be based on a correct differential electrocardiographic diagnosis to differentiate it from other arrhythmias, fundamentally the atrial tachycardia and in a complete study that allows us to identify the cause that causes it, or to rule out its existence. A 24-hour holter-ECG may be useful in the diagnosis of inappropriate sinus tachycardia. ManagementIn the case of appropriate sinus tachycardia, the treatment will correspond to the underlying pathology that has triggered the arrhythmia. For the inappropriate sinus tachycardia, the braking agents, particularly ivabradine, are useful because of their selective effect on the sinus node and its excellent hemodynamic profile, which makes them very safe and well tolerated drugs.

Innapropriate sinus tachycardia – cardiac syndrome or anxiety-related disorder?

IntroductionRelation between psychology, psychiatry and cardiology are multidimensional and begin to have growing importance in the diagnosis and treatment of patients of cardiosurgery, electrocardiology and cardiac rehabilitation. Inappropriate sinus tachycardia (IST) is a rarely diagnosed clinical syndrome characterized by excessive resting heart rate (HR) or disproportional increasing HR during exercise. The mechanisms of IST are not well understood. It is speculated that psychological factors might be of importance.AimsThe purpose of the study was to evaluate possible relation between the level of anxiety, personality traits and control of emotions, emotional intelligence, coping with stress strategies and manifestation of IST.MethodsThe participants were 23 women with a diagnosis of IST (age range 31.8 ± 8.72) and 23 women (28.7 ± 4.4) without cardiac diseases. The research applied psychological tools including: State–Trait Anxiety Inventory, NEO-Five Factor Inventory, Courtauld Emotional Control Scale, Emotional Intelligence Questionnaire, Coping Inventory for Stressful Situations and an originally developed sociodemographic questionnaire.ResultsIt has been found that that the group of women with IST received higher results in Trait Anxiety Inventory compared to the group of healthy women and the relation was highly statistically significant (P = 0,009). No other differences were found.ConclusionsInappropriate sinus tachycardia can be considered as an anxiety related disorder. However, its pathogenesis and classification position remains elusive.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Ein Herz ohne Drehzahlbegrenzung

We report the case of a 38-year patient who presented in our outpatient clinic for cardiac evaluation and assessment as volunteer firefighter. The patient had an asymptomatic sinustachycardia, which was diagnosed at the age of 15. After we excluded secondary etiologies, as well as a postural orthostatic tachycardia syndrome (POTS) diagnosis of inappropriate sinus tachycardia (IST) was confirmed. A metoprolol therapy was established, however to resistant tachycardia, we suggested a combined therapy of Bisoprolol and Ivabradin, which resulted successfully in normocard sinus rhythm.

Refractory inappropriate sinus tachycardia successfully treated with radiofrequency ablation at the arcuate ridge

Supraventricular tachycardias similar to sinus rhythm are difficult to evaluate and treat with catheter ablation. In addition to inappropriate sinus tachycardia (IST), curative ablation of atrial tachycardia arising from the crista terminalis is well described. We report the case of a 48-year-old woman with multiple failed ablation attempts for IST successfully ablated on the arcuate ridge. Ultrasound and fluoroscopy-guided mapping and ablation of this specific endocavitary anatomic site may be helpful in certain patients with the diagnosis of IST.

156 A single centre experience of Ivabradine and Clonidine for inappropriate sinus tachycardia

<h3>Introduction</h3> Inappropriate sinus tachycardia (IST) is a relatively rare disease that manifests with resting tachycardia, a rapid increase in heart rate (HR) with minimal exertion, a normal ECG and absence of structural heart disease. Treatment options include β-blockade or sinus node modification which are not 100% successful. Newer agents like sinus node inhibitor (Ivabradine) or a centrally acting α-2 sympathomimetic (Clonidine) can be used but there is no success outcome data for either and there is also no evidence that one is better than the other. We present our experience of managing 6 patients with a diagnosis of IST with either Ivabradine or Clonidine or both. <h3>Methods</h3> We identified 6 patients from 2005 to 2009 with a diagnosis of IST (according to accepted international guidelines) who had been treated with either Ivabradine or Clonidine or both. Medical case records were reviewed for each patient. <h3>Results</h3> 5 out of 6 patients were women with a mean age of 27.5 years (range 16–40 years). All patients had been symptomatic for alteast 6 months before presentation to our tertiary centre. 2 patients had associated symptoms of hyperadrenergic surges. Holter monitoring prior to treatment demonstrated sinus tachycardia. Resting pre-treatment mean 24 h HR was 94±10 (range 75–100) and mean HR on minimal exertion was 157±20 (range 130–176). All patients had a structurally normal heart on echocardiogram. Tilt table testing was considered in 3 patients due to their symptoms and it excluded postural orthostatic tachycardia syndrome. Pre-treatment with β-blockers had been unsuccessful in 5/6 patients. The remaining patient had symptomatic asthma and was therefore unable to tolerate β-blockers. Ivabradine was exclusively used in 3 patients and clonidine in 2. 1 patient was started with Ivabradine but later switched over to clonidine as it was ineffective. All 4 patients taking Ivabradine failed to gain symptom relief with no significant reduction in mean 24-h HR parameters. Mean resting HR after 3 months of Ivabradine therapy was 95±9 (range 88–105) and mean HR on exertion was 159±23 (range 128–180). 2/4 patients subsequently had complete sinus node ablation and AAIR pacemaker. In contrast, the 3 patients on clonidine had greater symptom resolution and fall in resting and exercise heart rates at 3 months follow-up. Resting mean HR was 81±3 (range 78–83) and mean HR with exertion was 144±18 (range 132–164). The HR variability pre and post treatment is shown in Abstract 156 figure 1. <h3>Discussion</h3> In our case series of 6 patients, Clonidine was more effective than Ivabradine both in terms of reducing heart rate and treating symptoms for patients with inappropriate sinus tachycardia. Patients with coexisting hyperadrenergic symptoms may benefit the most. A trial of Clonidine can be recommended before considering sinus node ablation. Formal randomised controlled trials are needed to confirm our findings.

Postural Tachycardia Syndrome associated with peripartum cardiomyopathy

Here we describe a 26-year-old woman who developed peripartum cardiomyopathy characterized by fatigue, poor exercise tolerance, and palpitations. Initial echocardiography showed global left ventricular dysfunction with an ejection fraction of 40%. Subsequently, the patient developed a resting tachycardia associated with symptomatic postural tachycardia. A diagnosis of Inappropriate Sinus Tachycardia was made based on Holter monitoring studies with an average heart rate of 121 beat per minute (bpm). Standard autonomic evaluation confirmed the diagnosis of Postural Tachycardia Syndrome. The cardiomyopathy subsequently resolved (ejection fraction 60%, normal left ventricular function). However, both the postural tachycardia and sinus tachycardia persisted.

Modification and ablation for inappropriate sinus tachycardia: current status.

Inappropriate sinus tachycardia is an ill-defined clinical syndrome with diverse clinical manifestations. Clinical symptoms can range from intermittent palpitations to multisystem complaints. Although there is a general consensus that when the heartbeat exceeds 100 beats per minute at rest or with minimal physiologic challenge, it is considered "inappropriate," this quantitative differentiation is quite arbitrary, while validation of the reproducibility of the heart rate/activity correlation can be challenging. Once the clinical diagnosis of inappropriate sinus tachycardia is expected, other supraventricular tachyarrhythmias and medical conditions causing sinus tachycardia should be excluded. The underlying mechanism of inappropriate sinus tachycardia is not well understood. "Intracardiac" mechanisms such as enhanced intrinsic automaticity, enhanced sympathetic tone, increased sympathetic receptor sensitivity, and blunted parasympathetic tone have been proposed. Evidences for "extracardiac" mechanisms such as length-dependent autonomic neuropathy, excessive venous pooling, beta-receptor hypersensitivity, alpha-receptor hyposensitivity, altered sympathovagal balance, and brainstem dysregulation have also been reported. Currently, our ability to differentiate primary (intracardiac) from secondary (extracardiac) mechanisms of inappropriate sinus tachycardia is limited. It has been reported that ablative therapy of sinus node is effective in treating patients with symptomatic inappropriate sinus tachycardia. Acute success of sinus node modification/ablation can be accomplished in 70%-100% of the various study populations. Although long-term successful outcome may be accomplished in a few patients, symptoms of palpitations and autonomic characteristics frequently persist. Identification and differentiation of patients who are suitable for ablative therapy versus medical therapy should be one of the central clinical research issues in this patient population. This brief review first considers the clinical and electrophysiologic diagnosis of inappropriate tachycardia and then summarizes the mechanisms of inappropriate sinus tachycardia and related syndromes such as postural orthostatic tachycardia syndrome. Techniques of mapping and ablation of sinus node are discussed briefly. A critical review of the acute and long-term clinical outcomes following sinus node ablation and modification is updated. In conclusion, the precise role of sinus node modification in patients with inappropriate sinus tachycardia remains to be determined. Sinus node modification could be considered in patients with inappropriate sinus tachycardia with persistently increased heart rate in the absence of any autonomic abnormalities. Autonomic laboratory testing should be performed to exclude any evidence of autonomic dysregulation. Clinical research on the pathophysiology of inappropriate sinus tachycardia should be pursued vigorously.

Inappropriate sinus tachycardia: evaluation and therapy.

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.