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October 28, 1983, Vol 250, No. 16 >
ARTICLE | October 28, 1983

Arrhythmias Associated With Sinus Node Dysfunction: Title and subTitle BreakPathogenesis, Recognition, and Management FREE

Martin A. Alpert, MD; Greg C. Flaker, MD
[+] Author Affiliations

Reprint requests to Room C-7, University of Missouri Health Sciences Center, 807 Stadium Rd, Columbia, MO 65212 (Dr Alpert).


JAMA. 1983;250(16):2160-2166. doi:10.1001/jama.1983.03340160046030
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References

DURING the past 15 years, we have become increasingly aware of the importance of arrhythmias associated with sinus node dysfunction as a cause of cardiac and neurological symptoms. These arrhythmias currently afflict more than 100,000 Americans, and as a group constitute the most common indication for permanent cardiac pacemaker implantation. The objectives of this review are (1) to discuss the pathogenesis and pathophysiology of arrhythmias associated with sinus node dysfunction, (2) to provide a clinical, electrocardiographic, and electrophysiological basis for their diagnosis, and (3) to discuss principles of management, including the use of the cardiac electrophysiology laboratory.

Anatomy and Pathophysiology  The sinus node is located in the posterior right atrial wall at the junction of the right atrium and superior vena cava.1 It consists of three types of cells: P cells, transitional cells, and Purkinje's cells.2,3 The P cells, which are located in the midst of a collagen

REFERENCES

1 +
James TN:  Anatomy of the human sinus node . Anat Rec 1961;;141:109-116.
2 +
James TN, Sherf L, Fine G:  Comparative ultrastructure of the sinus node in man and dog . Circulation 1966;;34:139-163.
3 +
Hudson R:  The conductive system , in Cardiovascular Pathology . Baltimore, Williams & Wilkins Co, 1965;, pp 53-66.
4 +
James TN:  The coronary circulation and conduction system in acute myocardial infarction . Prog Cardiovasc Dis 1968;;10:410-449.
5 +
Stetler WA, McMahon RA:  The innervation and structure of the conductive system of the human heart . J Comp Neurol 1947;;87:57-84.
6 +
James TN:  Cardiac innervation: Anatomic and pharmacologic relations . Bull NY Acad Med 1967;;43:1041-1086.
7 +
Ferrer MI:  The sick sinus syndrome . Circulation 1973;;47:635-641.
8 +
Moss AJ, Davis RJ:  Brady-tachy syndrome . Prog Cardiovasc Dis 1974;;16:439-454.
9 +
Kaplan BM, Langendorf R, Lev M, et al:  Tachycardia-bradycardia syndrome (so-called 'sick sinus syndrome'): Pathology, mechanisms, treatment . Am J Cardiol 1973;;31:497-508.
10 +
Ferrer MI:  The primary pacemaker: Functions, falterings and false alarms . Chest 1979;; 75:376-379.
11 +
Rubenstein JJ, Schulman C, Yurchak PM:  Clinical spectrum of sick sinus syndrome . Circulation 1972;;46:5-13.
12 +
Chung EK:  Sick sinus syndrome: Current views: Part I . Mod Concepts Cardiovasc Dis 1980;;49:61-66.
13 +
Chung EK:  Sick sinus syndrome: Current views: Part II . Mod Concepts Cardiovasc Dis 1980;;49:67-72.
14 +
Bigger JT, Reiffel JA:  Sick sinus syndrome . Annu Rev Med 1979;;30:91-118.
15 +
Jordan JL, Yamaguchi Q, Mandel WJ:  Studies on the mechanism of sinus node dysfunction in the sick sinus syndrome . Circulation 1978;;57:217-223.
16 +
Goldreyer BN:  Sinus node dysfunction: A physiologic consideration of arrhythmias involving the sinus node . Cardiovasc Clin 1974;;6:178-188.
17 +
Schullman CL, Rubenstein JJ, Yurchak RN, et al:  The 'sick sinus syndrome': Clinical spectrum . Circulation 1970;;42( (suppl 3) ):5-13.
18 +
Banka VS, Helfant RH:  Arrhythmias related to the sinus node , in Helfant RH (ed): Bellet's Essentials of Cardiac Arrhythmias . Philadelphia, WB Saunders Co, 1980;, pp 58-73.
19 +
Alpert MA:  Sinoatrial block and sinus arrest , in Cardiac Arrhythmias: A Bedside Guide to Diagnosis and Treatment . Chicago, Year Book Medical Publishers, 1980;, pp 128-143.
20 +
Marriott HJL, Myerbert RJ:  Recognition and treatment of cardiac arrhythmias and conduction disturbances , in Hurst JW (ed): The Heart , ed 7. New York, McGraw-Hill Book Co, 1978;, pp 677-679.
21 +
Parmeswaran R, Ohe T, Goldberg H:  Sinus node dysfunction in acute myocardial infarction . Br Heart J 1976;;38:93-97.
22 +
Reiffel JA, Bigger JT, Giardina EGV:  'Paradoxical' prolongation of sinus node recovery time after atropine in the sick sinus syndrome . Am J Cardiol 1975;;36:98-104.
23 +
Shaw RB, Mashford ML, Desmond PV:  Cardiac arrest after intravenous injection of cimetidine . Med J Aust 1980;;2:629-630.
24 +
James TN:  Interpretation of pathologic anatomy associated with arrhythmias and conduction disturbances , in Hurst JW (ed): The Heart , ed 7. New York, McGraw-Hill Book Co, 1978;, pp 609-620.
25 +
Evans R, Show DB:  Pathological studies in sinoatrial disorder (sick sinus syndrome) . Br Heart J 1977;;39:778-786.
26 +
Greenwood RS, Rosenthal A, Sloss LJ, et al:  Sick sinus syndrome after surgery for congenital heart disease . Circulation 1975;;52:208-213.
27 +
Spellberg RD:  Familial sinus node disease . Chest 1971;;60:246-251.
28 +
Allensworth DC, Rice GJ, Lowe GW:  Persistent atrial standstill in a family with myocardial disease . Am J Med 1969;;47:775-784.
29 +
Saracheck YS, Leonard JJ:  Familial heart block and sinus bradycardia: Classifications and natural history . Am J Cardiol 1972;;29:451-458.
30 +
DeSilva RA, Shubrooks SJ:  Mitral valve prolapse with atrioventricular and sinoatrial node abnormalities of long duration . Am Heart J 1977;;93:772-775.
31 +
Loeb JM, Euler DE, Randall WC:  Cardiac arrhythmias after chronic embolization of the sinus node artery: Alterations in parasympathetic control . Circulation 1980;;61:192-198.
32 +
Ferrer MI:  The etiology and natural history of sinus node disorders . Arch Intern Med 1982;;142:371-372.
33 +
Ferrer MI:  Rescue rhythms in the sick sinus syndrome: With special reference to slow atrial rhythm . Cardiovasc Rev Rep 1981;;2:149-152.
34 +
Ferrer MI:  Significance of slow atrial rhythm . Am J Cardiol 1980;;46:176-177.
35 +
Vera Z, Mason DT, Awan NA, et al:  Improvement of patients with sick sinus syndrome by spontaneous development of stable atrial fibrillation . Br Heart J 1977;;39:160-167.
36 +
Kay R, Estioko M, Weiner I:  Primary sick sinus syndrome as an indication for chronic pacemaker therapy in young adults: Incidence, clinical features and long-term evaluation . Am Heart J 1982;;103:338-341.
37 +
Bharati S, Nordenberg A, Bauerfiend R, et al:  Anatomic substrate for the sick sinus syndrome in adolescence . Am J Cardiol 1980;;46:163-172.
38 +
Fowler N, Fenton J, Conway G:  Syncope and cerebral dysfunction caused by bradycardia without atrioventricular block . Am Heart J 1970;;80:303-312.
39 +
Obel I, Cohen E, Miller R:  Chronic symptomatic sinoatrial block: A review of 34 patients and their treatment . Chest 1974;;65:397-402.
40 +
Agruss NS, Rosin EY, Adolph RJ, et al:  Significance of sinus bradycardia in elderly people . Circulation 1972;;46:924-930.
41 +
Van Durme JP:  Tachyarrhythmias and transient cerebral ischemic attacks . Am Heart J 1975;;89:538-540.
42 +
Fairfax AJ, Lambert CD:  Neurological aspects of sinoatrial heart block . J Neurol Neurosurg Psychiatry 1973;;39:576-580.
43 +
Fairfax AF, Lambert CD, Leatham A:  Systemic embolism in chronic sinoatrial disorder . N Engl J Med 1976;;295:190-192.
44 +
Samarasinghe HHR, Senanayake N:  Permanent neurological deficits complicating sinoatrial block . Br Heart J 1973;;35:503-506.
45 +
Crook BRM, Cashman RMM, Stott FD, et al:  Tape monitoring of the electrocardiogram in ambulant patients with sinoatrial disease . Br Heart J 1973;;35:1009-1013.
46 +
Reiffel JA, Bigger JT, Cramer M, et al:  Ability of Holter electrocardiographic recording and atrial stimulation to detect sinus node dysfunction in symptomatic and asymptomatic patients with sinus bradycardia . Am J Cardiol 1977;;40:189-194.
47 +
Talano JV, Euler D, Randall WC, et al:  Sinus node dysfunction: An overview with emphasis on autonomic and pharmacologic consideration . Am J Med 1978;;64:773-781.
48 +
Dhingra RC, Amat-Y-Leon F, Wyndham C:  Electrophysiologic effects of atropine on the sinus node and atrium in patients with sinus nodal dysfunction . Am J Cardiol 1976;;38:848-855.
49 +
Rosen KM, Loeb HS, Sinno ME:  Cardiac conduction in patients with symptomatic sinus node disease . Circulation 1971;;43:836-844.
50 +
Strauss HC, Bigger JT, Saroff AL, et al:  Electrophysiologic evaluation of sinus node function in patients with sinus node dysfunction . Circulation 1976;;53:763-776.
51 +
Mandel W, Hayakawa H, Allen HH:  Assessment of sinus node function in patients with the sick sinus syndrome . Circulation 1972;; 46:761-769.
52 +
Scheinman MM, Strauss HC, Abbott JA:  Electrophysiological testing for patients with sinus node dysfunction . J Electrocardiography 1979;;12:211-219.
53 +
Reiffel JA:  Principles and applications of electrophysiologic testing of sinus node function . Cardiovasc Med 1979;;4:97-102.
54 +
Narula OS, Samet P, Javier RP:  Significance of the sinus node recovery time . Circulation 1977;;55:8-15.
55 +
Reiffel JA, Gang E, Bigger JT, et al:  Sinus node recovery time related to paced cycle length in normals and patients with sinoatrial dysfunction . Am Heart J 1982;;104:746-752.
56 +
Okimoto T, Veda K, Kamata L, et al:  Sinus node recovery time and abnormal post-pacing phase in aged patients with sick sinus syndrome . Jpn Heart J 1976;;17:290-301.
57 +
Gupta RO, Lichstein E, Chadola KO, et al:  Appraisal of sinus node recovery time in patients with the sick sinus syndrome . Am J Cardiol 1974;;34:265-270.
58 +
Chadda KO, Banks VS, Bodenheimer M, et al:  Corrected sinus node recovery time: Experimental, physiologic and pathologic determinants . Circulation 1975;;51:797-801.
59 +
Dhingra RC, Amat-Y-Leon F, Wyndham C:  Clinical significance of prolonged sinoatrial conduction time . Circulation 1978;;58:8-15.
60 +
Crook B, Bibion P, McComich M, et al:  Indirect measurement of sinoatrial conduction time in patients with sinoatrial disease and in controls . Br Heart J 1977;;39:771-777.
61 +
Breithardt G, Seipel C:  Comparative study of two methods of estimating sinoatrial conduction time in man . Am J Cardiol 1978;;42:965-972.
62 +
Reiffel JA, Gang E, Glikich J, et al:  The human sinus node electrogram: A transvenous catheter technique and a comparison of directly measured and indirectly estimated sinoatrial conduction time . Circulation 1980;;62:1324-1334.
63 +
Gomes JAC, Kang PS, El-Sherif N:  The sinus node electrogram in patients without the sick sinus syndrome: Techniques and correlation between directly measured and indirectly estimated sinoatrial conduction time . Circulation 1982;;66:864-873.
64 +
Urtler G, Krawizynska E:  Diagnostic heart stimulation with an esophageal electrode in the sick sinus syndrome . Pol Arch Med Wewn 1977;;59:367-377.
65 +
Bredikis I, Rimsha E, Drog A, et al:  Transesophageal precardiac electrostimulation in a functional study of the sinus node . Kardiologiia 1981;;12:72-77.
66 +
Robinson BF, Epstein SE, Beiser GD, et al:  Control of the heart rate by the autonomic nervous system . Circ Res 1966;;19:400-411.
67 +
Alboni P, Malcarne C, Pedroni P, et al:  Electrophysiology of the normal sinus node with and without autonomic blockade . Circulation 1982;;65:1236-1241.
68 +
Kang PS, Gomes JAC, Kelen G, et al:  Role of autonomic regulatory mechanisms on sinoatrial conduction and sinus node automaticity in the sick sinus syndrome . Circulation 1981;;64:832-838.
69 +
Desai J, Scheinman MM, Strauss HC, et al:  Electrophysiologic effects of combined autonomic blockade in patients with sinus node disease . Circulation 1981;;63:953-959.
70 +
Kang PS, Gomes JAC, El-Sherif N:  Differential effects of functional autonomic blockade on the variables of sinus nodal automaticity in the sick sinus syndrome . Am J Cardiol 1982;; 49:273-282.
71 +
Jewell GM, Magorien RD, Schaal SF, et al:  Autonomic tone of patients during an electrophysiologic catheterization: The role of autonomic influences on the reproducibility of sinus node function studies . Am Heart J 1980;;99:51-57.
72 +
Shaw DB, Kekwick CA:  Potential candidates for pacemakers: Survey of heart block and sinoatrial disorders (sick sinus syndrome) . Br Heart J 1978;;40:99-105.
73 +
Krishnuswami V, Geraci AR:  Permanent pacing in sinus node dysfunction . Am Heart J 1975;;89:579-585.
74 +
Reiffel JA:  Drugs to avoid in patients with sinus node dysfunction . Drug Therapy 1982;; 12:99-106.
75 +
Breithardt G, Seipel L:  The influence of drugs on sinoatrial conduction time in man , in Luderitz B (ed): Cardiac Pacing . New York, Springer Publishing Co Inc, 1976;, p 58.
76 +
Strauss HC, Gilbert M, Svenson RH, et al:  Electrophysiologic effects of propranolol in patients with sinus node dysfunction . Circulation 1976;;54:452-459.
77 +
Reiffel JA, Bigger JT, Cramer M:  Effects of digoxin on sinus nodal function before and after vagal blockade in patients with sinus nodal dysfunction: A clue to the mechanism of action of digitalis on the sinus node . Am J Cardiol 1979;;43:983-989.
78 +
Margolis JR, Strauss HC, Miller HC, et al:  Digitalis and the sick sinus syndrome: Clinical and electrophysiologic documentation of severe toxic effect on sinus node function . Circulation 1975;;52:162-169.
79 +
Engel TR, Schaal SF:  The use of digoxin in the sick sinus syndrome , abstracted. Am J Cardiol 1973;;31:129.
80 +
Gomes JAC, Kang PS, El-Sherif N:  Effects of digitalis on the human sick sinus node after pharmacologic autonomic blockade . Am J Cardiol 1981;;48:783-788.
81 +
Vera Z, Awan NA, Mason DT, et al:  Assessment of oral quinidine effects on sinus node function in sick sinus syndrome patients . Am Heart J 1982;;103:80-84.
82 +
Grayzell J, Angeles J:  SA block in man provoked by quinidine . J Electrocardiol 1972;; 5:289-294.
83 +
Goldberg D, Reiffel JA, Davis JC, et al:  Electrophysiologic effects of procainamide on sinus function in patients with and without sinus node disease . Am Heart J 1982;;103:75-79.
84 +
LaBarre A, Strauss HC, Scheinman MM, et al:  Electrophysiologic effects of disopyramide phosphate on sinus node function in patients with sinus node dysfunction . Circulation 1976;; 59:226-235.
85 +
Carrasco HA, Fuenmayor A, Barboza JS, et al:  Effect of verapamil on normal sinoatrial node function and on the sick sinus syndrome . Am Heart J 1978;;96:760-771.
86 +
Scheinman MM, Strauss HC, Evans GT, et al:  Adverse effect of sympatholytic agents in patients with hypertension and sinus node dysfunction . Am J Med 1978;;64:1013-1020.
87 +
Radford DJ, Julian DG:  Sick sinus syndrome: Experience of a cardiac pacemaker clinic . Br Med J 1974;;3:504-507.
88 +
Simon A, Zloto A:  Symptomatic sinus node disease: Natural history after permanent ventricular pacing . PACE 1979;;2:305-312.
89 +
Alpert MA, Katti SK:  Natural history of sinus node dysfunction after permanent pacemaker implantation . South Med J 1982;;75:182-188.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
James TN:  Anatomy of the human sinus node . Anat Rec 1961;;141:109-116.
2 +
James TN, Sherf L, Fine G:  Comparative ultrastructure of the sinus node in man and dog . Circulation 1966;;34:139-163.
3 +
Hudson R:  The conductive system , in Cardiovascular Pathology . Baltimore, Williams & Wilkins Co, 1965;, pp 53-66.
4 +
James TN:  The coronary circulation and conduction system in acute myocardial infarction . Prog Cardiovasc Dis 1968;;10:410-449.
5 +
Stetler WA, McMahon RA:  The innervation and structure of the conductive system of the human heart . J Comp Neurol 1947;;87:57-84.
6 +
James TN:  Cardiac innervation: Anatomic and pharmacologic relations . Bull NY Acad Med 1967;;43:1041-1086.
7 +
Ferrer MI:  The sick sinus syndrome . Circulation 1973;;47:635-641.
8 +
Moss AJ, Davis RJ:  Brady-tachy syndrome . Prog Cardiovasc Dis 1974;;16:439-454.
9 +
Kaplan BM, Langendorf R, Lev M, et al:  Tachycardia-bradycardia syndrome (so-called 'sick sinus syndrome'): Pathology, mechanisms, treatment . Am J Cardiol 1973;;31:497-508.
10 +
Ferrer MI:  The primary pacemaker: Functions, falterings and false alarms . Chest 1979;; 75:376-379.
11 +
Rubenstein JJ, Schulman C, Yurchak PM:  Clinical spectrum of sick sinus syndrome . Circulation 1972;;46:5-13.
12 +
Chung EK:  Sick sinus syndrome: Current views: Part I . Mod Concepts Cardiovasc Dis 1980;;49:61-66.
13 +
Chung EK:  Sick sinus syndrome: Current views: Part II . Mod Concepts Cardiovasc Dis 1980;;49:67-72.
14 +
Bigger JT, Reiffel JA:  Sick sinus syndrome . Annu Rev Med 1979;;30:91-118.
15 +
Jordan JL, Yamaguchi Q, Mandel WJ:  Studies on the mechanism of sinus node dysfunction in the sick sinus syndrome . Circulation 1978;;57:217-223.
16 +
Goldreyer BN:  Sinus node dysfunction: A physiologic consideration of arrhythmias involving the sinus node . Cardiovasc Clin 1974;;6:178-188.
17 +
Schullman CL, Rubenstein JJ, Yurchak RN, et al:  The 'sick sinus syndrome': Clinical spectrum . Circulation 1970;;42( (suppl 3) ):5-13.
18 +
Banka VS, Helfant RH:  Arrhythmias related to the sinus node , in Helfant RH (ed): Bellet's Essentials of Cardiac Arrhythmias . Philadelphia, WB Saunders Co, 1980;, pp 58-73.
19 +
Alpert MA:  Sinoatrial block and sinus arrest , in Cardiac Arrhythmias: A Bedside Guide to Diagnosis and Treatment . Chicago, Year Book Medical Publishers, 1980;, pp 128-143.
20 +
Marriott HJL, Myerbert RJ:  Recognition and treatment of cardiac arrhythmias and conduction disturbances , in Hurst JW (ed): The Heart , ed 7. New York, McGraw-Hill Book Co, 1978;, pp 677-679.
21 +
Parmeswaran R, Ohe T, Goldberg H:  Sinus node dysfunction in acute myocardial infarction . Br Heart J 1976;;38:93-97.
22 +
Reiffel JA, Bigger JT, Giardina EGV:  'Paradoxical' prolongation of sinus node recovery time after atropine in the sick sinus syndrome . Am J Cardiol 1975;;36:98-104.
23 +
Shaw RB, Mashford ML, Desmond PV:  Cardiac arrest after intravenous injection of cimetidine . Med J Aust 1980;;2:629-630.
24 +
James TN:  Interpretation of pathologic anatomy associated with arrhythmias and conduction disturbances , in Hurst JW (ed): The Heart , ed 7. New York, McGraw-Hill Book Co, 1978;, pp 609-620.
25 +
Evans R, Show DB:  Pathological studies in sinoatrial disorder (sick sinus syndrome) . Br Heart J 1977;;39:778-786.
26 +
Greenwood RS, Rosenthal A, Sloss LJ, et al:  Sick sinus syndrome after surgery for congenital heart disease . Circulation 1975;;52:208-213.
27 +
Spellberg RD:  Familial sinus node disease . Chest 1971;;60:246-251.
28 +
Allensworth DC, Rice GJ, Lowe GW:  Persistent atrial standstill in a family with myocardial disease . Am J Med 1969;;47:775-784.
29 +
Saracheck YS, Leonard JJ:  Familial heart block and sinus bradycardia: Classifications and natural history . Am J Cardiol 1972;;29:451-458.
30 +
DeSilva RA, Shubrooks SJ:  Mitral valve prolapse with atrioventricular and sinoatrial node abnormalities of long duration . Am Heart J 1977;;93:772-775.
31 +
Loeb JM, Euler DE, Randall WC:  Cardiac arrhythmias after chronic embolization of the sinus node artery: Alterations in parasympathetic control . Circulation 1980;;61:192-198.
32 +
Ferrer MI:  The etiology and natural history of sinus node disorders . Arch Intern Med 1982;;142:371-372.
33 +
Ferrer MI:  Rescue rhythms in the sick sinus syndrome: With special reference to slow atrial rhythm . Cardiovasc Rev Rep 1981;;2:149-152.
34 +
Ferrer MI:  Significance of slow atrial rhythm . Am J Cardiol 1980;;46:176-177.
35 +
Vera Z, Mason DT, Awan NA, et al:  Improvement of patients with sick sinus syndrome by spontaneous development of stable atrial fibrillation . Br Heart J 1977;;39:160-167.
36 +
Kay R, Estioko M, Weiner I:  Primary sick sinus syndrome as an indication for chronic pacemaker therapy in young adults: Incidence, clinical features and long-term evaluation . Am Heart J 1982;;103:338-341.
37 +
Bharati S, Nordenberg A, Bauerfiend R, et al:  Anatomic substrate for the sick sinus syndrome in adolescence . Am J Cardiol 1980;;46:163-172.
38 +
Fowler N, Fenton J, Conway G:  Syncope and cerebral dysfunction caused by bradycardia without atrioventricular block . Am Heart J 1970;;80:303-312.
39 +
Obel I, Cohen E, Miller R:  Chronic symptomatic sinoatrial block: A review of 34 patients and their treatment . Chest 1974;;65:397-402.
40 +
Agruss NS, Rosin EY, Adolph RJ, et al:  Significance of sinus bradycardia in elderly people . Circulation 1972;;46:924-930.
41 +
Van Durme JP:  Tachyarrhythmias and transient cerebral ischemic attacks . Am Heart J 1975;;89:538-540.
42 +
Fairfax AJ, Lambert CD:  Neurological aspects of sinoatrial heart block . J Neurol Neurosurg Psychiatry 1973;;39:576-580.
43 +
Fairfax AF, Lambert CD, Leatham A:  Systemic embolism in chronic sinoatrial disorder . N Engl J Med 1976;;295:190-192.
44 +
Samarasinghe HHR, Senanayake N:  Permanent neurological deficits complicating sinoatrial block . Br Heart J 1973;;35:503-506.
45 +
Crook BRM, Cashman RMM, Stott FD, et al:  Tape monitoring of the electrocardiogram in ambulant patients with sinoatrial disease . Br Heart J 1973;;35:1009-1013.
46 +
Reiffel JA, Bigger JT, Cramer M, et al:  Ability of Holter electrocardiographic recording and atrial stimulation to detect sinus node dysfunction in symptomatic and asymptomatic patients with sinus bradycardia . Am J Cardiol 1977;;40:189-194.
47 +
Talano JV, Euler D, Randall WC, et al:  Sinus node dysfunction: An overview with emphasis on autonomic and pharmacologic consideration . Am J Med 1978;;64:773-781.
48 +
Dhingra RC, Amat-Y-Leon F, Wyndham C:  Electrophysiologic effects of atropine on the sinus node and atrium in patients with sinus nodal dysfunction . Am J Cardiol 1976;;38:848-855.
49 +
Rosen KM, Loeb HS, Sinno ME:  Cardiac conduction in patients with symptomatic sinus node disease . Circulation 1971;;43:836-844.
50 +
Strauss HC, Bigger JT, Saroff AL, et al:  Electrophysiologic evaluation of sinus node function in patients with sinus node dysfunction . Circulation 1976;;53:763-776.
51 +
Mandel W, Hayakawa H, Allen HH:  Assessment of sinus node function in patients with the sick sinus syndrome . Circulation 1972;; 46:761-769.
52 +
Scheinman MM, Strauss HC, Abbott JA:  Electrophysiological testing for patients with sinus node dysfunction . J Electrocardiography 1979;;12:211-219.
53 +
Reiffel JA:  Principles and applications of electrophysiologic testing of sinus node function . Cardiovasc Med 1979;;4:97-102.
54 +
Narula OS, Samet P, Javier RP:  Significance of the sinus node recovery time . Circulation 1977;;55:8-15.
55 +
Reiffel JA, Gang E, Bigger JT, et al:  Sinus node recovery time related to paced cycle length in normals and patients with sinoatrial dysfunction . Am Heart J 1982;;104:746-752.
56 +
Okimoto T, Veda K, Kamata L, et al:  Sinus node recovery time and abnormal post-pacing phase in aged patients with sick sinus syndrome . Jpn Heart J 1976;;17:290-301.
57 +
Gupta RO, Lichstein E, Chadola KO, et al:  Appraisal of sinus node recovery time in patients with the sick sinus syndrome . Am J Cardiol 1974;;34:265-270.
58 +
Chadda KO, Banks VS, Bodenheimer M, et al:  Corrected sinus node recovery time: Experimental, physiologic and pathologic determinants . Circulation 1975;;51:797-801.
59 +
Dhingra RC, Amat-Y-Leon F, Wyndham C:  Clinical significance of prolonged sinoatrial conduction time . Circulation 1978;;58:8-15.
60 +
Crook B, Bibion P, McComich M, et al:  Indirect measurement of sinoatrial conduction time in patients with sinoatrial disease and in controls . Br Heart J 1977;;39:771-777.
61 +
Breithardt G, Seipel C:  Comparative study of two methods of estimating sinoatrial conduction time in man . Am J Cardiol 1978;;42:965-972.
62 +
Reiffel JA, Gang E, Glikich J, et al:  The human sinus node electrogram: A transvenous catheter technique and a comparison of directly measured and indirectly estimated sinoatrial conduction time . Circulation 1980;;62:1324-1334.
63 +
Gomes JAC, Kang PS, El-Sherif N:  The sinus node electrogram in patients without the sick sinus syndrome: Techniques and correlation between directly measured and indirectly estimated sinoatrial conduction time . Circulation 1982;;66:864-873.
64 +
Urtler G, Krawizynska E:  Diagnostic heart stimulation with an esophageal electrode in the sick sinus syndrome . Pol Arch Med Wewn 1977;;59:367-377.
65 +
Bredikis I, Rimsha E, Drog A, et al:  Transesophageal precardiac electrostimulation in a functional study of the sinus node . Kardiologiia 1981;;12:72-77.
66 +
Robinson BF, Epstein SE, Beiser GD, et al:  Control of the heart rate by the autonomic nervous system . Circ Res 1966;;19:400-411.
67 +
Alboni P, Malcarne C, Pedroni P, et al:  Electrophysiology of the normal sinus node with and without autonomic blockade . Circulation 1982;;65:1236-1241.
68 +
Kang PS, Gomes JAC, Kelen G, et al:  Role of autonomic regulatory mechanisms on sinoatrial conduction and sinus node automaticity in the sick sinus syndrome . Circulation 1981;;64:832-838.
69 +
Desai J, Scheinman MM, Strauss HC, et al:  Electrophysiologic effects of combined autonomic blockade in patients with sinus node disease . Circulation 1981;;63:953-959.
70 +
Kang PS, Gomes JAC, El-Sherif N:  Differential effects of functional autonomic blockade on the variables of sinus nodal automaticity in the sick sinus syndrome . Am J Cardiol 1982;; 49:273-282.
71 +
Jewell GM, Magorien RD, Schaal SF, et al:  Autonomic tone of patients during an electrophysiologic catheterization: The role of autonomic influences on the reproducibility of sinus node function studies . Am Heart J 1980;;99:51-57.
72 +
Shaw DB, Kekwick CA:  Potential candidates for pacemakers: Survey of heart block and sinoatrial disorders (sick sinus syndrome) . Br Heart J 1978;;40:99-105.
73 +
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To understand the clinical management of acute heart failure syndromes.
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Compression-Only CPR: Pushing the Science Forward
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AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
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