Wandering Atrial Pacemaker

KEY FEATURES

ESSENTIALS OF DIAGNOSIS

• Progressive cyclic variation in P-wave morphology

• Heart rate 60–100 bpm

• Variation of P-wave morphology, P-P interval, and P-R interval

GENERAL CONSIDERATIONS

• This rhythm is benign

• This rhythm and multifocal atrial tachycardia are similar except for heart rate

• The other possible explanation is that there is significant respiratory sinus arrhythmia, with uncovering of latent foci of pacemaker activity

• Usually, it is associated with underlying lung disease

• In the elderly, it may be a manifestation of sick sinus syndrome

• In the young and athletic heart, it may represent enhanced vagal tone

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

• Usually causes no symptoms and is incidentally discovered

• Occasional patient may feel skipped beats

PHYSICAL EXAM FINDINGS

• Variable S₁

DIFFERENTIAL DIAGNOSIS

• Multifocal atrial tachycardia (heart rate > 100 bpm)

• Frequent premature atrial complexes and atrial bigeminy

DIAGNOSTIC EVALUATION

LABORATORY TESTS

• None specific

ELECTROCARDIOGRAPHY

• ECG to document rhythm

TREATMENT

CARDIOLOGY REFERRAL

• Not required

MEDICATIONS

• No specific treatment

• Monitor and treat the underlying cause, such as sick sinus syndrome or lung disease

DIET AND ACTIVITY

• No restrictions

• General healthy lifestyle

ONGOING MANAGEMENT

FOLLOW-UP

• Once a year if sinus node abnormality is suspected; otherwise when symptoms arise

COMPLICATIONS

• May progress to sick sinus syndrome

PROGNOSIS

• This condition by itself is benign

RESOURCES

PRACTICE GUIDELINES

• Indications for pacemaker:

  • – If part of sick sinus syndrome

  • – If associated with documented symptomatic bradycardia

REFERENCES