Treatment of sick sinus syndrome

Emergency treatment of sinus node weakness syndrome in the development of dizziness, syncopal conditions, severe asystole against bradycardic rhythm disturbances includes the introduction of vagolytic drugs (atropine) or drugs with pronounced beta-adrenomimetic activity (isoprenaline).

The tactic of removing a child from a syncopal condition is an indirect cardiac massage and artificial respiration. The introduction of one of the following drugs is indicated:

• epinephrine in a dose of 0.05 mg / year IM or iv once;
• isoprenaline in / m 0.5-1.0 ml (0.1-0.2 mg) IM or IV once;
• atropine 0.1% solution iv in a dose of 0.01-0.02 mg / kg, not more than 2.0 mg;
• Phenylephrine 1% solution in / m 0.1 ml / year of life (not more than 1.0 ml).

With persistence of severe bradyarrhythmia accompanied by symptoms of weakness, dizziness, pre-syncopal and syncopal conditions, the child should be taken to a hospital where the issue of the need for electrical stimulation of the heart will be solved.

The goals of maintenance, long-term therapy are to prevent the progression of sinus node lesions and the development of complications (fits of loss of consciousness, critical bradyarrhythmia). Reduce the degree of impairment of the functional state of the sinus node.

The basis of drug treatment is stimulating therapy with a wide range of action, resorption, membrane-stabilizing and metabolic therapy. The following principles should be considered in treatment:

• preparations of different groups are administered in a complex, not sequentially;
• At the same time, do not prescribe more than three preparations of the main groups of oral use;
• treatment should be long (not less than 6 months for variant I and not less than 12 months for more severe violations of the functions of the sinus node);
• the drugs of one group, if necessary for a prolonged course of treatment, alternate and are prescribed in cycles of 2-3 months;
• all drugs are prescribed in generally accepted age-related doses;
• observation of the patient should be regular (at least 1 time in 6 months) and long (at least 1 year) after the normalization of the rhythm;
• It is necessary to obtain survey data or to remove ECG from all relatives of the first and second degree of kinship;
• to control the effectiveness of treatment in each child choose a method that allows the most reliable to judge the individual dynamics of electrophysiological disturbances in the myocardium.

In all cases of weakness syndrome of the sinus node, the appointment of adaptogens and preparations with nootropic action is indicated: ginseng, eleutherococcus spiny rhizome and roots, glutamic acid, gamma-aminobutyric acid, pyrithinol. Use metabolic drugs: multivitamins + other drugs (vitrum beauty, coenzyme Q10). Carnitine, meldonium (mildronate). With a high representation of the substitutive heterotopic rhythm of high frequency and attachment of arrhythmogenic myocardial dysfunction in children with the III variant of the syndrome, it may be necessary to perform antiarrhythmic therapy under the control of heart rate according to ECG and Holter monitoring. Antiarrhythmic therapy is contraindicated in children with a syncope in history, expressed by depression of the functions of the sinus node, the presence of a large number of pauses of the rhythm according to the Holter monitoring data and / or the concomitant violation of AV-conduction. In the IV variant of the syndrome, stimulant and metabolic therapy is carried out for a longer period (at least 6 months). When detecting high titers of autoantibodies against cells of the conduction system of the heart (1: 160 and above), courses of NSAIDs and hydroxychloroquine (plaquenella) are recommended.

After AV blockade, a high degree of weakness syndrome of the sinus node is the most frequent indication for the pacemaker: this operation accounts for 20 to 50% of the total number of implants in adults.

Indications I class to the implantation of the pacemaker in children with sinus syndrome weakness syndrome:

• recurrence of arrhythmogenic syncope attacks on the background of therapy;
• documented symptomatic bradycardia in patients with a syndrome of sinus node weakness with a heart rate below critical for a given age.

Class IIa of indications:

• tachycardia-bradycardia syndrome (III variant of the syndrome of weakness of the sinus node, leading to the need for antiarrhythmic therapy:
• asymptomatic sinus bradycardia with heart rate at rest less than 35 per minute and rhythm pauses more than 3 seconds in children with congenital heart anomalies.

Class IIb readings:

• syncope, associated with severe bradycardia, without the effect of ongoing therapy;
• the child has asymptomatic pauses of the rhythm for more than 3 seconds on the background of complex medication therapy, conducted for at least 3 months;
• asymptomatic sinus bradycardia with heart rate at rest less than 35 per minute;
• binodalnaya disease with symptoms of the AV node (AV blockade II-III degree).

Class III indications: symptomatic sinus bradycardia in adolescents with rhythm pauses of less than 3 seconds and minimum heart rate at rest more than 40 per minute.

The principles of assessing the effectiveness of treatment for children with sinus syndrome are different from those for other disorders of rhythm and conduction. One of the differences is the need for a clear and reliable recording of the dynamics of not only qualitative but also quantitative indicators, which is caused by a large number of ECG phenomena in almost every patient. In the event that there is no positive dynamics, but the manifestations of the syndrome are not exacerbated, in spite of the generally accepted ideas, it is necessary to state a "conditionally positive result". The latter situation we justify the progressing course of the disease in the absence of adequate treatment. Consequently, the stabilization of the electrocardiographic picture indicates the suspension of the further development of the pathological process.

Forecast

Adverse sensory signs in children with syndrome of sinus node weakness are fits of loss of consciousness, a progressive decrease in the mean daily, maximum and minimum daily and night heart rate as measured by Holter monitoring, an increase in the number and duration of rhythm pauses, the appearance of additional rhythm and conduction disorders, an inadequate increase in heart rate sinus rhythm during a sample with a dosed physical exertion, aggravation or provocation of additional s rhythm disorders. Prognostically unfavorable family cases of the disease. Sudden cardiac death in families with direct relatives in young (up to 40 years) age is considered as an unfavorable prognosis factor.