Inappropriate sinus tachycardia

Inappropriate sinus tachycardia (IST) is a rare[1] type of cardiac arrhythmia within the category of supraventricular tachycardia (SVT). IST may be caused by the sinus node itself having an abnormal structure or function, or it may be part of a problem called dysautonomia, a disturbance and/or failure of the autonomic nervous system. Research into the mechanism and etiology (cause) of inappropriate sinus tachycardia is ongoing.

Inappropriate sinus tachycardia
Other namesIST
SpecialtyCardiology

IST is viewed by most to be a benign condition in the long-term. Symptoms of IST, however, may be distracting and warrant treatment. The heart is a strong muscle and typically can sustain the higher-than-normal heart rhythm, though monitoring the condition is generally recommended.[2] The mechanism and primary etiology of inappropriate sinus tachycardia has not been fully elucidated. An autoimmune mechanism has been suggested, as several studies have detected autoantibodies that activate beta adrenoreceptors in some patients.[3][4] The mechanism of the arrhythmia primarily involves the sinus node and peri-nodal tissue[5] and does not require the AV node for maintenance. Treatments in the form of pharmacological therapy or catheter ablation are available, but the condition is currently difficult to treat successfully.

Symptoms

Symptoms reported by patients vary in frequency and severity. They may include:

Diagnosis

No formal diagnostic criteria exist. A diagnosis of inappropriate sinus tachycardia is primarily one of exclusion,[7] and the following may be observed:[8]

Treatment

IST has been treated both pharmacologically and invasively, with varying degrees of success. IST, in and of itself, is not indicative of higher rates of mortality, and non-treatment is an option chosen by many if they have minimal symptoms.[2]

Some types of medication tried by cardiologists and other physicians include: beta blockers, selective sinus node If channel inhibitors (such as ivabradine),[9] calcium channel blockers, and antiarrhythmic agents. Some SSRI drugs are also occasionally tried, as are treatments more commonly used to treat postural orthostatic tachycardia syndrome, such as fludrocortisone.

Invasive treatments include forms of catheter ablation such as sinus node modification[10] (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). However, invasive treatments can also make the symptoms worse.

Differential diagnoses

IST is primarily a diagnosis of exclusion.[7] Upon exertion, an inappropriate heart rate response of sinus tachycardia can be seen in some Inborn Errors of Metabolism that result in metabolic myopathies, such as McArdle Disease (GSD-V).[11][12] Rare diseases are more likely to be misdiagnosed, indeed, "Ninety percent of people with GSD V received a misdiagnosis before a corrected diagnosis (GSD VII unknown), resulting in a median diagnostic delay of 29 years, which can seriously affect QoL [Quality of Life]… Of those who are misdiagnosed, 62% report being misdiagnosed more than once."[11]

See also

References
  1. Şimşek, Evrim; Ozbay, Benay; Mutlu, Inan; Gurses, Ecem; Kemal, Hatice S; Yagmur, Burcu; Can, Levent Hürkan (2020). "Prevalence of inappropriate sinus tachycardia and the comparison of the heart rate variability characteristics with propensity score-matched controls". Archives of the Turkish Society of Cardiology. 48 (2): 96–102. doi:10.5543/tkda.2019.92735. ISSN 1016-5169.
  2. Olshansky, Brian; Sullivan, Renee M. (February 2013). "Inappropriate Sinus Tachycardia". Journal of the American College of Cardiology. 61 (8): 793–801. doi:10.1016/j.jacc.2012.07.074.
  3. Chiale, Pablo A.; Garro, Hugo A.; et al. (October 2006). "Inappropriate sinus tachycardia may be related to an immunologic disorder involving cardiac β andrenergic receptors". Heart Rhythm. 3 (10): 1182–1186. doi:10.1016/j.hrthm.2006.06.011.
  4. Nattel, Stanley (October 2006). "Inappropriate sinus tachycardia and beta-receptor autoantibodies: A mechanistic breakthrough?". Heart Rhythm. 3 (10): 1187–1188. doi:10.1016/j.hrthm.2006.07.019.
  5. Sato, Toshiaki; Mitamura, Hideo; et al. (October 2000). "Electrophysiologic findings of a patient with inappropriate sinus tachycardia cured by selective radiofrequency catheter ablation". Journal of Electrocardiology. 33 (4): 381–386. doi:10.1054/jelc.2000.9648.
  6. Femenía, Francisco; Baranchuk, Adrian; et al. (2012). "Inappropriate Sinus Tachycardia: Current Therapeutic Options". Cardiology in Review. 20 (1): 008–014. doi:10.1097/CRD.0b013e31822f0b3e.
  7. Ahmed, Adnan; Pothineni, Naga Venkata K.; Charate, Rishi; et al. (2022-06-21). "Inappropriate Sinus Tachycardia: Etiology, Pathophysiology, and Management: JACC Review Topic of the Week". Journal of the American College of Cardiology. 79 (24): 2450–2462. doi:10.1016/j.jacc.2022.04.019. ISSN 0735-1097.
  8. Nwazue, Victor C.; Paranjape, Sachin Y.; Black, Bonnie K.; Biaggioni, Italo; Diedrich, André; Dupont, William D.; Robertson, David; Raj, Satish R. (March 24, 2014). "Postural Tachycardia Syndrome and Inappropriate Sinus Tachycardia: Role of Autonomic Modulation and Sinus Node Automaticity". Journal of the American Heart Association. 3 (2): e000700. doi:10.1161/JAHA.113.000700. PMC 4187519. PMID 24721800.
  9. Zellerhoff, Stephan; Hinterseer, Martin; et al. (December 2010). "Ivabradine in patients with inappropriate sinus tachycardia". Naunyn-Schmiedeberg's Archives of Pharmacology. 382 (5–6): 483–486. doi:10.1007/s00210-010-0565-y.
  10. Lee, Randall J.; Kalman, Jonathan M.; et al. (15 November 1995). "Radiofrequency Catheter Modification of the Sinus Node for "Inappropriate" Sinus Tachycardia". Circulation. 92 (10): 2919–2928. doi:10.1161/01.CIR.92.10.2919.
  11. Lucia A, Martinuzzi A, Nogales-Gadea G, Quinlivan R, Reason S, et al. (International Association for Muscle Glycogen Storage Disease study group) (Dec 2021). "Clinical practice guidelines for glycogen storage disease V & VII (McArdle disease and Tarui disease) from an international study group". Neuromuscul Disord. 31 (12): 1296–1310. doi:10.1016/j.nmd.2021.10.006. PMID 34848128. Epub 2021 Oct 28. Erratum: Lucia A, et al. (Feb 2022). "Erratum to "Clinical practice guidelines for glycogen storage disease V & VII (McArdle disease and Tarui disease) from an international study group" [Neuromuscular Disorders 31 (2021) 1296-1310]". Neuromuscular disorders. 32 (2). e3. doi:10.1016/j.nmd.2022.01.004. Epub 2022 Feb 6.
  12. Wakelin, Andrew (2017). Living With McArdle Disease (PDF). IAMGSD (International Association of Muscle Glycogen Storage Disease). p. 15.

Further reading
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