What are the implications of sinus pauses on telemetry (electrocardiographic monitoring)?

From the Guidelines

For sinus pauses on telemetry, the first step is to assess if the patient is symptomatic, and if so, notify the physician immediately and prepare for possible intervention, as symptomatic patients may require permanent pacing to improve symptoms and quality of life 1. When evaluating sinus pauses, it's essential to consider the patient's symptoms, as asymptomatic patients with brief pauses may not require immediate intervention.

• Key factors to consider include:
  • Symptom correlation with sinus bradycardia or pauses
  • Duration and frequency of pauses
  • Associated heart rate and any symptoms
  • Electrolyte abnormalities, particularly potassium and magnesium
  • Medications that may slow heart rate, such as beta-blockers, calcium channel blockers, and digoxin According to the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay, permanent cardiac pacing is indicated in patients with symptoms directly attributable to sinus node dysfunction (SND) to increase heart rate and improve symptoms 1.
• The guideline recommends avoiding medications that slow heart rate and correcting electrolyte abnormalities, particularly potassium and magnesium.
• Atropine 0.5-1mg IV may be used for temporary management of symptomatic bradycardia with pauses. In asymptomatic patients with brief pauses, continued monitoring is recommended, but immediate intervention may not be necessary, as the risk of complications from permanent pacemaker placement may outweigh the benefits 1. It's crucial to weigh the benefits of permanent pacing against the risks of procedural complications and long-term management implications, especially in asymptomatic patients.
• The decision to implant a permanent pacemaker should be based on the presence of symptoms and the correlation between symptoms and sinus bradycardia or pauses, rather than the presence of pauses alone 1.

From the Research

Sinus Pauses on Telemetry

If sinus pauses are observed on telemetry, several steps can be taken:

• Monitor the patient closely to promptly recognize any arrhythmia and prevent an unexplained rapid decline in cardiopulmonary status 2
• Investigate potential causes of sinus pauses, such as:
  • Hypoxemia, cytokine storm, dysautonomia, direct viral infiltration, and surrounding myocardial inflammation in patients with COVID-19 2
  • Sleep apnea syndrome, which can cause significant sinus pauses during sleep 3, 4
  • Sick sinus syndrome, which can be diagnosed using electrophysiologic studies and may require pacemaker implantation 5, 6
• Consider the patient's medical history and symptoms, and perform diagnostic tests such as Holter monitoring or electrophysiologic studies to determine the underlying cause of the sinus pauses 5, 6, 3, 4
• Develop a treatment plan based on the underlying cause, which may include:
  • Pacemaker implantation for patients with sick sinus syndrome or other indications 5, 6
  • Treatment with nasal continuous positive airway pressure (nCPAP) for patients with sleep apnea syndrome 4
  • Management of underlying conditions such as COVID-19 or other cardiovascular diseases 2