Inappropriate sinus tachycardia

Inappropriate sinus tachycardia (IST) is an uncommon type of cardiac arrhythmia, within the category of supraventricular tachycardia (SVT). The mechanism and primary etiology of Inappropriate sinus tachycardia has not been fully elucidated. The mechanism of the arrhythmia primarily involves the Sinus Node and peri-nodal tissue¹ and does not require the AV Node (Atrioventricular node) for maintenance. Treatments in the form of pharmacological therapy or Catheter ablation are available, although it is currently difficult to treat successfully.

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Symptoms

Symptoms reported by patients vary in frequency and severity.

Symptoms associated with Inappropriate sinus tachycardia include:

• Frequent Palpitations
• Dyspnea (Shortness of Breath) and Palpitations on exertion
• Pre-Syncope (feeling as if about to faint)
• Fatigue (physical)
• Dizziness
• Exercise intolerance
• Occasional Paresthesia and cramping
• Symptoms associated with Autonomic nervous system disturbance, including GI disturbance

Diagnosis

No formal diagnostic criteria exist. A diagnosis of Inappropriate sinus tachycardia is primarily one of exclusion and the following may be observed:

• Exclusion of all other causes of Sinus tachycardia
• Common forms of Supraventricular tachycardia (SVT) must be excluded
• Normal P wave morphology
• A resting Sinus tachycardia is usually (but not always) present
• Nocturnal dip in Heart rate
• Inappropriate Heart rate response on exertion
• Mean Heart rate in 24hrs >95bpm
• Symptoms are documented to be due to tachycardia
• Hypotension is occasionally observed
• Syncope (fainting) is occasionally reported

Treatment

IST has been treated both pharmacologically and invasively, with varying degrees of success.

Some types of medication tried by cardiologists and other physicians include: Beta blockers, Calcium channel blockers and Antiarrhythmic agents. Some SSRI drugs are also occasionally tried and also treatments more commonly used to treat Postural orthostatic tachycardia syndrome such as Fludrocortisone. This approach is very much "trial-and-error". Patients with IST are often intolerant to Beta blockers. A new selective sinus node inhibitor Ivabradine is also being used to treat IST.

Invasive treatments include forms of Catheter ablation such as Sinus Node Modification² (selective ablation of the Sinus Node), Complete Sinus Node Ablation (with associated implantation of a Permanent Artificial pacemaker) and AV Node Ablation in very resistant cases (creation of iatrogenic complete heart block, necessitating implantation of a Permanent Artificial pacemaker).

See also

• supraventricular tachycardia
• Sinus tachycardia
• Postural orthostatic tachycardia syndrome
• Dysautonomia

References

Note 1: Sato T, Mitamura H, Murata M, Shinagawa K, Miyoshi S, Kanki H, Takatsuki S, Soejima K, Miyazaki T, Ogawa S. Electrophysiologic findings of a patient with inappropriate sinus tachycardia cured by selective radiofrequency catheter ablation. J Electrocardiol. 2000 Oct;33(4):381-6. Medline Abstract

Note 2: 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. Circulation Abstract

Yusuf S, Camm AJ. Deciphering the sinus tachycardias. Clin Cardiol. 2005 Jun;28(6):267-76. Review. Medline Abstract

AM Still, P Raatikainen, A Ylitalo, H Kauma, M Ikaheimo, Y Antero Kesaniemi, and HV Huikuri. Prevalence, characteristics and natural course of inappropriate sinus tachycardia. Europace, March 1, 2005; 7(2): 104-12. Medline Abstract

Leon H, Guzman JC, Kuusela T, Dillenburg R, Kamath M, Morillo CA. Impaired baroreflex gain in patients with inappropriate sinus tachycardia. J Cardiovasc Electrophysiol. 2005 Jan;16(1):64-8. Erratum in: J Cardiovasc Electrophysiol. 2005 Feb;16(2):109. Medline Abstract

Sanchez-Quintana D, Cabrera JA, Farre J, Climent V, Anderson RH, Ho SY. Sinus node revisited in the era of electroanatomical mapping and catheter ablation. Heart. 2005 Feb;91(2):189-94. Medline Abstract

Cruz Filho FE, Maia IG, Fagundes ML, Boghossian S, Ribeiro JC. Arq Bras Cardiol. Sinus node modification by catheter using radiofrequency current in a patient with inappropriate sinus tachycardia. Evaluation of early and late results. 1998 Mar;70(3):173-6. Portuguese. Medline Abstract

Shih-Huang Lee1, Jun-Jack Cheng1, Peiliang Kuan1, Chi-Ren Hung. Radiofrequency Catheter Modification of Sinus Node for Inappropriate Sinus Tachycardia: A Case Report. Chin Med J (Taipei) ;60:117-23. 1997. Full Text Article