Which condition would be easier to treat: Sick Sinus Syndrome or Heart Block?

I have often wondered which condition would be easier to manage/treat:   Sick Sinus Syndrome (SSS) or Heart Block (HB).  I have just seen opposing views from two valued members and I thought it would be interesting to do a post on this and to get some more views.

I know this is not a straightforward question because both SSS and HB can be changeable and sometimes improve or worsen, requiring more or less in the way of management/treatment.  Both conditions are not always 100% present at any one time.   Also both conditions may be present to a certain degree at the same time, complicating the picture even further. 

So which condition do you feel would be easier to treat in general, Sick Sinus Syndrome or Heart Block and why?  Your thoughts and personal experience managing either condition would be valuable.


Simplistic View Perhaps?

by Penguin - 2023-11-07 07:51:22

My view comes from the potential for pacing to cause further harm.  It's a simplistic view.

CHB involves v.pacing and there are known risks that come with VP.

SSS involves a.pacing and we are told that a.pacing isn't dangerous. 

Therefore (personally) I'd be more concerned about a CHB diagnosis and it's management / progression if a pacemaker was the main treatment rather than an SSS diagnosis.  

Heart Block

by Lavender - 2023-11-07 08:14:18

Heart block with a working sinus node is easy to treat with a CRT-P. You're fixed. I don't even need any meds. 

Sick Sinus Syndrome takes more management. 

Best to have neither but ....................

by IAN MC - 2023-11-07 08:30:24

Mine also is a simplistic view and I only have personal experience of Sick Sinus Syndrome.

With S.S.S. you are far more likely to suffer from Chronotropic Incompetence than with heart block. This can lead to SSS sufferers having an impaired quality of life when they  exercise. So with SSS you are more likely to need the Rate Response feature of your pacemaker switching on than with heart block.

In my experience, Rate Response , with all its limitations ,is never as good as having a fully functioning sinus node.




by Penguin - 2023-11-07 08:40:27

Quick question: Why does simple SSS (uncomplicated with no arrhythmia) take more management? 

Do people with SSS really take more meds in addition to pacing for SSS or does the pacemaker take care of the bradycardia? In my case the pacing is the only treatment.

  Could more meds in people dx'd SSS be due to SSS mainly affecting the older generation? 

I'm genuinely interested rather than trying to score points here! 

I take Ian's point (and Crusty's previous point) about CI and exercise. 


by Lavender - 2023-11-07 09:23:24

As per Ian's comment, there can be exercise adjustments. I don't know if SSS patients take more meds-it depends on co-existing issues. Like many heart conditions, it can become progressively worse as we age. Pacemakers greatly improve the quality of life. If I had a choice, I'd choose NEITHER heart block nor SSS🙃

A Wide Spectrum of Outcomes in Either Case

by DoingMyBest - 2023-11-07 11:21:52

"Which condition would be easier to treat: Sick Sinus Syndrome or Heart Block?"
There are multiple facets to this question and the answer depends on which affects you most.

In the simplest sense, SSS is the "easiest" to treat. Single-lead to the atrium and you're done.

But then, there are the questions of Quality of Life (comfort), and longevity. How simple is it to treat one or the other to maximize these outcomes?

With SSS there are a lot of rate response issues that effect QoL. Not so much with HB. In this sense SSS is more difficult.

But, with HB there seems to be more likelihood of Congestive Heart Failure (CHF), low Ejection Fraction (EF), promotion of arrhythmias, and ectopic beats. There are difficulties associated with lead placement - RVAP, RVSP, HBP, LBBP, LBBAP, CRT. There can be lots of different combinations of blocks - AV node ablation, 1st degree, 2nd degree, 3rd degree, Mobitz Type I, Mobitz Type II, RBBB, LBBB, LAFB, LPFB. Given all these variables and potential outcomes, perhaps HB is more difficult to treat.

Honestly, I think its going to depend on the individual. Some cases of SSS are simple. Some cases of HB are simple. Some of each are horrible and no amount of treatment is the perfect fix. Perhaps the "numbers" say one type is easier than the other to treat, but that's little solice to someone who is suffering.

I don't think it's fair to call either type of treatment easier than the other. It just depends. Some people are lucky. Some are not.

Rate Response & CI

by Penguin - 2023-11-07 12:15:26

Could I throw in a few more questions?  These relate to CI, which seems to be the main complication that people are concerned about in SSS.

1) Can autonomic dysfunction cause Chronotropic Incompetence and is this understood currently? 

2) Are there any scenarios in which Rate Response can be  a harmful treatment e.g. when CI is diagnosed alongside a low EF% or Heart failure ? 

3) Does CI affect the prognosis of SSS? 


Both conditions can be equally difficult to treat

by Gemita - 2023-11-07 16:08:45

Thank you Penguin, Lavender, Ian, DoingMyBest for your contributions.  I have to admit, I don’t really know how best to answer my own question even after reading all your answers.  It is just not that simple, is it? 

Both Sick Sinus Syndrome (SSS) and Heart Block (HB) are electrical disturbances that can overlap, so we are often not treating one condition in isolation.  I for example have both SSS and occasional HB, so although I am mainly atrial paced, the right ventricle lead is still needed and active at times and I suspect it is the same for many of us, so it will not always be a simple single lead to the right atrium and we are done with SSS.

As you have pointed out there are many different types of HB too, some perhaps more difficult to treat or tolerate than others.  There are also many different features of SSS from Sinus Bradycardia, Chronotropic Incompetence to Tachycardia-Bradycardia syndrome, to name just a few.  

I certainly wouldn’t want to be heavily paced in the right ventricle, at least not without a CRT device because of the potential for Pacemaker Induced Cardiomyopathy possibly leading to heart failure.  More importantly, I do not feel comfortable being paced in the right ventricle, so for this reason alone I am glad that my problems are mainly confined to the atria.   I know however that many of you with HB are perfectly comfortable being paced in the right ventricle, so what makes some of us more symptomatic than others with either SSS or HB, I wonder?

Perhaps with Bradycardia or uncomplicated HB and no other disturbances of rhythm, we can remain symptom free for many years especially with a well placed, well adjusted pacemaker. However electrical disturbances are rarely simple in nature, or stay the same.

I wholeheartedly agree getting our heart rate to rise when we exercise is not straightforward with SSS.  I still struggle with exercise during an arrhythmia that would affect my capacity to exercise in any event.  My beta blocker also adversely affects my capacity to exercise.

Can autonomic dysfunction cause chronotropic incompetence (CI)?  My CI was first identified during autonomic testing for another condition. I was exercising for over 30 mins with no increase in heart rate.  CI was diagnosed well before SSS or Atrial Fibrillation were seen.

Rate Response (RR).  Can it be harmful when treating a patient for CI with a low EF or heart failure?  I believe as long as the patient listens to his/her body and doesn't push through difficult symptoms like chest pain or breathlessness, then RR can only help to improve quality of life.  It helps my husband with his heart failure.

Does CI affect the prognosis of SSS?  CI can adversely affect the prognosis of some conditions and is an added complication that will require settings adjustments.  Pushing through difficult symptoms during exercise with CI and a poorly adjusted pacemaker could trigger worsening symptoms like increased palpitations, chest pain, breathlessness

heart block

by dwelch - 2023-11-18 23:21:46

I assume we are all going to vote for the one we have/know.  56 years with heart block (didnt know it for a dozen or so) 36 years with pacers.  The pacer completely fixes it, done...

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