Significance of ventricular pauses of three seconds or more detected on twenty-four-hour holter recordings

doi:10.1016/0002-9149(85)90735-0

The American Journal of Cardiology

Volume 55, Issue 8, 1 April 1985, Pages 1005-1008

https://doi.org/10.1016/0002-9149(85)90735-0 Get rights and content

Abstract

The natural history of patients with asymptomatic prolonged ventricular pauses and the indications for permanent pacing are controversial. To examine this problem, 6,470 consecutive 24-hour Holter recordings were reviewed between 1979 and 1983 for the presence of ventricular pauses of at least 3 seconds. Fifty-two patients (0.8% of total), 22 men and 30 women, were identified with an average longest pause duration of 4.1 seconds. Holter recordings were requested to evaluate syncope in 14 patients (27%), dizziness in 9 (17%) and other reasons in 29 (56%). Causes of the pauses were sinus arrest in 22 patients, atrial fibrillation with slow ventricular response in 18 patients and atrioventricular block in 12. Holter recordings were also evaluated for the presence of tachyarrhythmias. Six patients had nonsustained ventricular tachycardia and 7 had supraventricular tachycardia. Five of the 52 patients (10%) had dizziness or syncope during pauses. Twenty-six patients (50%) received permanent pacemakers. The paced (26 patients) and unpaced (26 patients) groups were similar in the length and etiology of pause, associated tachyarrhythmias, presence of bradycardia-related symptoms, prevalence of organic heart disease, medications and length of follow-up. Four patients in the paced group and 2 in the unpaced group died, yielding 3-year actuarial survival probabilities of 78% and 85%, respectively. It is concluded that ventricular pauses of 3 seconds or longer are uncommon, these pauses usually do not cause symptoms, and the presence of these pauses does not necessarily portend a poor prognosis or the need for pacing in asymptomatic patients. Address for reprints: Pablo Denes, MD, Rush-Presbyterian-St. Luke's Medical Center, 1753 West Congress Parkway, Chicago, Illinois 60612.

References (9)

M Mazuz et al.
Significance of prolonged electrocardiographic pauses in sinoatrial disease: sick sinus syndrome
Am J Cardiol
(1983)
L Gould
Three hundred and fifty-three consecutive patients with permanent transvenous pacemakers
PACE
(1980)
M Alpert
Factors influencing prognosis following permanent pacemaker implantation
Practical Cardiology
(1983)
MA Alpert et al.
Natural history of sinus node dysfunction after permanent pacemaker implantation
South Med J
(1982)

There are more references available in the full text version of this article.

Cited by (54)

Bradyarrhythmia in a marathonist: Cardiac vagal denervation as alternative treatment
2023, Revista Portuguesa de Cardiologia
Although not routinely used, cardioneuroablation or modulation of the cardiac autonomic nervous system has been proposed as an alternative approach to treat young individuals with enhanced vagal tone and significant atrioventricular (AV) disturbances.
We report the case of a 42-year-old athlete with prolonged ventricular pauses associated with sinus bradycardia and paroxysmal episodes of AV block (maximum of 6.6 s) due to enhanced vagal tone who was admitted to our hospital for pacemaker implantation. Cardiac magnetic resonance and stress test were normal. Although he was asymptomatic, safety concerns regarding possible neurological damage and sudden cardiac death were raised, and he accordingly underwent electrophysiological study (EPS) and cardiac autonomic denervation. Mapping and ablation were anatomically guided and radiofrequency pulses were delivered at empirical sites of ganglionated plexi. Modulation of the parasympathetic system was confirmed through changes in heart rate and AV nodal conduction properties associated with a negative cardiac response to atropine administration.
After a follow-up of nine months, follow-up 24-hour Holter revealed an increase in mean heart rate and no AV disturbances, with rare non-significant ventricular pauses, suggesting that this technique may become a safe and efficient procedure in this group of patients.
Ainda que raramente utilizada, a cardioneuroablação ou modulação do sistema nervoso autónomo cardíaco tem vindo a ser proposta como abordagem alternativa ao tratamento de indivíduos jovens com tónus vagal aumentado e, consequentemente, perturbações significativas da condução auriculoventricular (AV).
É apresentado um caso de um homem, atleta de 42 anos, referenciado para implantação de pacemaker por bradicardia sinusal e bloqueio auriculoventricular (BAV) de predomínio noturno por provável hipertonia vagal. As pausas noturnas por bradicardia sinusal associada a BAV atingiam os 6,6 segundos. Exames de imagem e prova de esforço foram normais. O doente foi submetido a estudo eletrofisiológico (EP) e desenervação autonómica cardíaca. O mapeamento e a ablação foram guiados anatomicamente, tendo sido aplicada energia por radiofrequência, de forma empírica, em locais da aurícula esquerda e direita onde previamente tinha sido descrita a existência de plexos ganglionares. A modulação do sistema parassimpático foi confirmada através da variação da frequência cardíaca e das propriedades de condução nodal AV no final do procedimento e ainda através de resposta cardíaca negativa à administração de atropina.
No seguimento de nove meses, o Holter de 24 horas evidenciou aumento da frequência cardíaca média e ausência de perturbações significativos da condução AV, sugerindo que essa técnica poderá vir a constituir uma alternativa à implantação de pacemaker neste subgrupo de doentes.
Bradyarrhythmias
2022, Practical Cardiology: Principles and Approaches
Bradyarrhythmias encompass a number of rhythm disturbances including sinus node dysfunction (SND) and atrioventricular block (AVB). Bradyarrhythmia may be asymptomatic and detected during routine electrocardiographic (ECG) examination or presented with dizziness, fatigue, syncope, presyncope, exercise intolerance, and poor concentration. Symptomatic SND is called sick sinus syndrome (SSS). ECG presentations of SND are sinus bradycardia, sinus pause or arrest, sinoatrial exit block, chronotropic incompetence, and tachy-brady syndrome. Symptom–rhythm correlation is highly important in SSS diagnosis. The initial clues to the diagnosis of SSS are most often gleaned from the patient's history, and the diagnosis is confirmed by a 12-lead surface ECG, ambulatory ECG recording, or exercise stress testing. In SND, treatment should be limited to those patients with a good symptom–rhythm correlation. Asymptomatic patients do not need any treatment. AVB is traditionally classified as first-, second-, or third-degree (complete) AV block. On the basis of intracardiac recordings, supra-, intra-, or infra-Hisian block can be differentiated. Diagnosis of AVB can be established in most cases noninvasively by the 12-lead ECG. In intermittent AVB, ambulatory ECG monitoring and exercise testing are important to establish a symptom–rhythm correlation. Except for asymptomatic first-degree AVB, type 1 second-degree AVB, and reversible types, other types of AVBs need a pacemaker, irrespective of associated symptoms.
Vasovagal syncope with asystole during repeated emesis in the emergency department
2021, American Journal of Emergency Medicine
Citation Excerpt :
The pause or arrest often allows escape beats or rhythms to occur, but lower pacemakers may be sluggish or even absent in SA node dysfunction. A pause that is two seconds or less is generally considered benign in the literature, but longer episodes of sinus arrest can produce symptoms of dizziness, presyncope, syncope, and, rarely, death [9]. In our patient's case, there was no evidence of junctional escape, or other idioventricular rhythms during the episodes in question, suggesting true asystole.
Prolonged sinus pause following ingestion of a button battery
2019, Progress in Pediatric Cardiology
Citation Excerpt :
This pause may be as short as 2 s but may last longer and is believed to be secondary to an alteration in discharge by the sinus node. During the pause, escape beats may originate in an ectopic fashion from the atrium, the atrioventricular node, or the ventricles [4,5]. The differential diagnosis of sinus pause includes sinus node fibrosis as a result of a degenerative process (seen mostly in adults), medications and toxins, familial disease, infiltrative and inflammatory diseases, sinus node artery disease and trauma during cardiac surgery (Table 1).
Para-esophageal inflammation secondary to button battery ingestion may rarely irritate the vagus nerve causing prolonged sinus pauses. We report such a case in a two-year-old who presented with prolonged sinus pauses noted on telemetry following button battery ingestion. A comprehensive evaluation deemed hyper-stimulation of the parasympathetic input to the sinus node as the possible etiology. This was determined to be most likely due to irritation and excessive stimulation of the vagus nerve secondary to para-esophageal inflammation. Because of the underlying mechanism of the sinus pauses, treatment with anti-cholinergic/anti-inflammatory agents was pursued with significant improvement in the clinical presentation. The case highlights the need to delineate the mechanism of sinus pauses in patients, as it may be reversible. Treatment directed at the underlying etiology is indicated to prevent inappropriate consideration/placement of a permanent pacemaker and avoid its associated co-morbidities, especially in the pediatric population.
Bradyarrhythmias
2019, Medicine (Spain)
Las bradiarritmias suponen una situación de frecuencia ventricular inferior a 60 latidos por minuto, debida a alteraciones en la generación o conducción del impulso cardíaco. Generalmente ocurren por degeneración del sistema de excitoconducción cardíaco, aunque existen múltiples causas secundarias, siendo algunas de ellas reversibles. Pueden cursar siendo asintomáticas o presentarse como parada cardiorrespiratoria o con situaciones intermedias de síntomas como disnea, astenia o ángor. El diagnóstico se basa en la monitorización cardíaca, generalmente con electrocardiograma de 12 derivaciones, aunque en ocasiones se hace precisa la monitorización prolongada e incluso la realización de estudios invasivos. El tratamiento definitivo suele reservarse para las bradiarritmias sintomáticas o para aquellas con mal pronóstico, y consiste en la estimulación cardíaca permanente mediante el implante de marcapasos.
Bradyarrhythmias are defined as a heart rate below 60 beats per minute, caused by either generation or conduction disorders of impulses in the heart. Although there are several secondary etiologies, some of them reversible, the degeneration of excitoconduction system is its main cause. Clinically appear either as asymptotic or as cardiorespiratory arrest; also, intermediate situations can be identified (dyspnea, asthenia or angor). The diagnosis is based on cardiac monitoring, usually with a 12-lead electrocardiogram; however, at times, prolonged monitoring and even invasive studies are required. Pacemaker is the definitive treatment, mainly reserved for symptomatic or poor prognosis bradyarrhythmias
2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society
2019, Heart Rhythm

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Significance of ventricular pauses of three seconds or more detected on twenty-four-hour holter recordings

Abstract

Am J Cardiol

Three hundred and fifty-three consecutive patients with permanent transvenous pacemakers

PACE

Factors influencing prognosis following permanent pacemaker implantation

Practical Cardiology

Natural history of sinus node dysfunction after permanent pacemaker implantation

South Med J