The origins of the sinus node pacemaker complex in man: Demonstration of dominant and subsidiary foci

J. Anthony Gomes, Stephen L. Winters

Research output: Contribution to journalArticle

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Abstract

To test the hypothesis that the human sinus node is capable of demonstrating multiple sites of impulse generation, we assessed spontaneous shifts in the sinus node pacemaker complex, and shifts after overdrive atrial pacing, premature atrial stimulation and carotid sinus massage. A total of 24 patients aged 59 ± 15 years (mean ± SD) in whom stable sinus node electrograms were obtained were selected for the study. Ten of the 24 patients had sick sinus syndrome, whereas 14 had no sinus node dysfunction. All 24 patients had atrial pacing at cycle lengths of 1,000 to 300 ms; 9 patients had premature atrial stimulation and 12 had carotid sinus massage. Shifts in the sinus node pacemaker complex occurred spontaneously in 4 (17%) of the 24 patients; after atrial pacing at cycle lengths of 800 to 300 ms (mean 387 ± 92) in 15 (63%) of 24 patients; after premature atrial stimulation at one or more coupling intervals in 5 (56%) of 9 patients and during carotid sinus massage in 9 (75%) of 12 patients. Shifts in the sinus node pacemaker complex lasted one to six beats and returned to the original site within two to seven beats. Spontaneous shifts in the sinus node pacemaker complex occurred in 3 of 14 patients without sick sinus syndrome and were induced in 6 (60%) of 10 patients with sick sinus syndrome and 11 (79%) of 14 patients without sick sinus syndrome. Shifts in sinus node pacemaker complex were characterized by 1) loss of primary negativity, 2) change in P wave morphology, 3) significant (p < 0.001) prolongation of sinoatrial interval and sinus cycle length. Conclusion: 1) Shifts in sinus node pacemaker complex occur frequently after rapid atrial pacing, premature atrial stimulation and carotid sinus massage and rarely occur spontaneously; 2) the subsidiary sinus node pacemaker complex is an escape pacemaker with a longer cycle length than the dominant sinus node pacemaker; 3) atrial pacing at rapid cycle lengths for assessing sinus node recovery times frequently assesses properties of the subsidiary sinus node pacemaker rather than that of the dominant pacemaker; and 4) this study suggests that the human sinus node has dominant and subsidiary foci.

Original languageEnglish (US)
Pages (from-to)45-52
Number of pages8
JournalJournal of the American College of Cardiology
Volume9
Issue number1
DOIs
StatePublished - Jan 1 1987

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Sinoatrial Node
Sick Sinus Syndrome
Carotid Sinus
Massage

All Science Journal Classification (ASJC) codes

  • Cardiology and Cardiovascular Medicine

Cite this

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title = "The origins of the sinus node pacemaker complex in man: Demonstration of dominant and subsidiary foci",
abstract = "To test the hypothesis that the human sinus node is capable of demonstrating multiple sites of impulse generation, we assessed spontaneous shifts in the sinus node pacemaker complex, and shifts after overdrive atrial pacing, premature atrial stimulation and carotid sinus massage. A total of 24 patients aged 59 ± 15 years (mean ± SD) in whom stable sinus node electrograms were obtained were selected for the study. Ten of the 24 patients had sick sinus syndrome, whereas 14 had no sinus node dysfunction. All 24 patients had atrial pacing at cycle lengths of 1,000 to 300 ms; 9 patients had premature atrial stimulation and 12 had carotid sinus massage. Shifts in the sinus node pacemaker complex occurred spontaneously in 4 (17{\%}) of the 24 patients; after atrial pacing at cycle lengths of 800 to 300 ms (mean 387 ± 92) in 15 (63{\%}) of 24 patients; after premature atrial stimulation at one or more coupling intervals in 5 (56{\%}) of 9 patients and during carotid sinus massage in 9 (75{\%}) of 12 patients. Shifts in the sinus node pacemaker complex lasted one to six beats and returned to the original site within two to seven beats. Spontaneous shifts in the sinus node pacemaker complex occurred in 3 of 14 patients without sick sinus syndrome and were induced in 6 (60{\%}) of 10 patients with sick sinus syndrome and 11 (79{\%}) of 14 patients without sick sinus syndrome. Shifts in sinus node pacemaker complex were characterized by 1) loss of primary negativity, 2) change in P wave morphology, 3) significant (p < 0.001) prolongation of sinoatrial interval and sinus cycle length. Conclusion: 1) Shifts in sinus node pacemaker complex occur frequently after rapid atrial pacing, premature atrial stimulation and carotid sinus massage and rarely occur spontaneously; 2) the subsidiary sinus node pacemaker complex is an escape pacemaker with a longer cycle length than the dominant sinus node pacemaker; 3) atrial pacing at rapid cycle lengths for assessing sinus node recovery times frequently assesses properties of the subsidiary sinus node pacemaker rather than that of the dominant pacemaker; and 4) this study suggests that the human sinus node has dominant and subsidiary foci.",
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The origins of the sinus node pacemaker complex in man : Demonstration of dominant and subsidiary foci. / Anthony Gomes, J.; Winters, Stephen L.

In: Journal of the American College of Cardiology, Vol. 9, No. 1, 01.01.1987, p. 45-52.

Research output: Contribution to journalArticle

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