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| __NOTOC__ | | __NOTOC__ |
| {{SI}} | | {{Junctional bradycardia}} |
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| | '''For patient information, click [[Junctional bradycardia (patient information)|here]]''' |
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| {{CMG}}; {{AE}} {{M.P}} | | {{CMG}}; {{AE}} {{M.P}} |
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| {{SK}} Junctional escape; junctional escape rhythm | | {{SK}} Junctional escape; junctional escape rhythm |
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| ==Overview== | | ==[[Junctional bradycardia overview|Overview]]== |
| Junctional bradycardia is a slow (40 to 60 beats per minute) narrow complex escape rhythm that originates in the [[atrioventricular node]] to compensate for slow or impaired conduction of pacemaker activity in the atrium.
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| ==Pathophysiology==
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| Normally, the [[atrioventricular node]] ([[AVN]]) can generate an escape rhythm of 40-60 beats per minute in case the [[sinoatrial node]] ([[SA node]]) or atrial pacemakers fail ([[sinus arrest]]) or slow ([[sinus bradycardia]]) or if there is [[complete heart block]]. This [[junctional escape rhythm]] generates a normal, narrow [[QRS complex]] rhythm at a rate below 60 beats per minute (junctional bradycardia) as the electrical impulses once they are generated are conducted with normal velocity down the usual pathways. [[Retrograde P waves]] (i.e. upside down) [[P waves]] due to retrograde or backward conduction may or may not be present.
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| ==Causes==
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| ===Life Threatening Causes===
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| Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
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| *[[Acute coronary syndrome]]
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| *[[acute renal failure|Acute hyperkalemic renal failure]]
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| *[[Diabetic ketoacidosis]]
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| *[[Myocardial rupture]]
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| *[[NSTEMI]]
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| *[[organophosphate|Organophosphate poisoning]]
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| *[[parathion|Parathion poisoning]]
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| *[[spider bite#spider venom|Poisonous spider bites]]
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| *[[brain damage|Severe brain injury]]
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| *[[STEMI]]
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| ===Common Causes===
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| *[[Acetylcholine]]
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| * [[Acute rheumatic fever]]
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| *[[Amiodarone]]
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| * [[Antiarrhythmic agents]]
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| * [[Beta-blockers]]
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| * [[Calcium channel blockers]]
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| *[[Cardiac catheterization]]
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| * [[Digitalis toxicity]]
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| *[[Dilated cardiomyopathy]]
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| *[[Diltiazem]]
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| *[[Hyperkalemia]]
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| *[[Hypermagnesemia]]
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| *[[Hypertensive heart disease]]
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| * [[Ischemic heart disease]]
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| *[[Methylprednisolone]]
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| *[[Phenytoin]]
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| * [[Sick sinus syndrome]]
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| * [[Sinus arrest]]
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| * [[Sinus bradycardia]]
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| * [[STEMI]]
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| *[[Verapamil]]
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| ===Causes by Organ System===
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| {|style="width:80%; height:100px" border="1"
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| |style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" |
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| '''Cardiovascular'''
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| |style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[Acute coronary syndrome]], [[acute rheumatic fever]], [[Andersen cardiodysrhythmic periodic paralysis]], [[Brugada syndrome]], [[cardiac tumor#heart in lymphomas|cardiac lymphoma]], [[cardiac tumor]], [[Carotid sinus hypersensitivity|cardioinhibitory syncope]], [[congenital heart disease]], [[congestive heart failure]], [[reperfusion injury|coronary reperfusion therapy]], [[dilated cardiomyopathy]], [[hypertensive heart disease]], [[hypertrophic cardiomyopathy]], [[ischemic heart disease]], [[Jervell and Lange-Nielsen syndrome]], [[long QT syndrome]], [[myocardial infarction]], [[myocardial rupture]], [[myocarditis]], [[NSTEMI]], [[pericarditis]], [[Romano-Ward syndrome]], [[sick sinus syndrome]], [[sinus arrest]], [[sinus bradycardia]], [[sinoatrial arrest|sinus node fibrosis]], [[STEMI]], [[tachycardia-bradycardia syndrome]], [[Timothy syndrome]], [[valvular heart disease]]
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| |-
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| |bgcolor="LightSteelBlue"| '''Chemical/Poisoning'''
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| |bgcolor="Beige"| [[Berberine]], [[grayanotoxin]], [[organophosphate|organophosphate poisoning]], [[parathion|parathion poisoning]], [[spider bite#spider venom|poisonous spider bites]], [[pyrethroid|pyrethroid poisoning]], [[Arizona bark scorpion|scorpion toxin]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Dental'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Dermatologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Drug Side Effect'''
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| |bgcolor="Beige"| [[Acetylcholine]], [[all-trans retinoic acid]], [[amiodarone]], [[anthracyclines]], [[antiarrhythmic drugs]], [[barbiturate]], [[beta-blockers]], [[bupivacaine]], [[calcium channel blockers]], [[carbamazepine]], [[cholinesterase inhibitors]], [[cimetidine]], [[citalopram]], [[clonidine]], [[digitalis]], [[digoxin]], [[diltiazem]], [[diphenhydramine]], [[donepezil]], [[edrophonium]], [[neostigmine]], [[granisetron]], [[guanethidine]], [[halothane]], [[idarubicin]], [[isoprenaline|isoprenaline infusion]], [[lithium]], [[mepivacaine]], [[mesalamine]], [[methyldopa]], [[methylprednisolone]], [[nelfinavir]], [[nicorandil]], [[phenothiazine]], [[phenytoin]], [[procainamide]], [[propafenone]], [[propanolol]], [[propofol]], [[pyridostigmine]], [[remifentanil]], [[reserpine]], [[ropivacaine]], [[tacrine]], [[thiamylal]], [[timolol]], [[tricyclic antidepressants]], [[urapidil]], [[verapamil]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Ear Nose Throat'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Endocrine'''
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| |bgcolor="Beige"| [[Diabetic ketoacidosis]], [[Hashimoto's thyroiditis]], [[pheochromocytoma]], [[hypothyroidism|profound hypothyroidism]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Environmental'''
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| |bgcolor="Beige"| [[Berberine]], [[hypothermia]], [[spider bite#spider venom|poisonous spider bites]], [[Arizona bark scorpion|scorpion toxin]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Gastroenterologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Genetic'''
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| |bgcolor="Beige"| [[Andersen cardiodysrhythmic periodic paralysis]], [[Brugada syndrome]], [[congenital heart disease]], [[Emery-Dreifuss muscular dystrophy]], [[Jervell and Lange-Nielsen syndrome]], [[Limb-girdle muscular dystrophy|limb-girdle muscular dystrophy type 1B (LGMD1B)]], [[muscular dystrophy]], [[myotonic dystrophy]], [[Romano-Ward syndrome]], [[Timothy syndrome]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Hematologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Iatrogenic'''
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| |bgcolor="Beige"| [[Cardiac catheterization]], [[cardiac transplantation]], [[coronary artery bypass grafting]], [[Fontan procedure]], [[heart surgery]], [[regional anesthesia|infraclavicular brachial plexus block]], [[lung transplantation|post lung transplantation]], [[tilt table testing|tilt testing]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Infectious Disease'''
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| |bgcolor="Beige"| [[Acute rheumatic fever]], [[Chagas disease]], [[diptheria]], [[Lyme disease]], [[myocarditis]], [[pericarditis]], [[septic shock]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Musculoskeletal/Orthopedic'''
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| |bgcolor="Beige"| [[Muscular dystrophy]], [[myotonic dystrophy]], [[Timothy syndrome]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Neurologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Nutritional/Metabolic'''
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| |bgcolor="Beige"| [[Hypermagnesemia]], [[metabolic acidosis]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Obstetric/Gynecologic'''
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| |bgcolor="Beige"| [[Small for gestational age|Very low birth weight infants]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Oncologic'''
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| |bgcolor="Beige"| [[cardiac tumor#heart in lymphomas|Cardiac lymphoma]], [[cardiac tumor]], [[multiple myeloma]], [[pheochromocytoma]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Ophthalmologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Overdose/Toxicity'''
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| |bgcolor="Beige"| [[All-trans retinoic acid]], [[amiodarone]], [[barbiturate]], [[digitalis]], [[digoxin]], [[halothane]], [[isoprenaline|isoprenaline infusion]], [[lithium]], [[propanolol]], [[cholinesterase inhibitors]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Psychiatric'''
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| |bgcolor="Beige"| [[Takotsubo cardiomyopathy]], [[anorexia nervosa|severe anorexia nervosa]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Pulmonary'''
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| |bgcolor="Beige"| [[Hypoxia]], [[lung transplantation|post lung transplantation]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Renal/Electrolyte'''
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| |bgcolor="Beige"| [[Acute renal failure]], [[hyperkalemia]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Rheumatology/Immunology/Allergy'''
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| |bgcolor="Beige"| [[Acute rheumatic fever]], [[scleroderma]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Sexual'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Trauma'''
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| |bgcolor="Beige"| [[Myocardial rupture]], [[brain damage|severe brain injury]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Urologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Miscellaneous'''
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| |bgcolor="Beige"| [[Amyloidosis]], [[idiopathic]]
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| |-
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| |}
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| ===Causes in Alphabetical Order===
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| {{col-begin|width=80%}}
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| {{col-break|width=33%}}
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| *[[Acetylcholine]]
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| *[[Acute coronary syndrome]]
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| *[[Acute renal failure]]
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| *[[Acute rheumatic fever]]
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| *[[All-trans retinoic acid]]<ref name="pmid22778455">{{cite journal| author=McGregor A, Hurst E, Lord S, Jones G| title=Bradycardia following retinoic acid differentiation syndrome in a patient with acute promyelocytic leukaemia. | doi=10.1136/bcr.02.2012.5848 | issue= | journal=BMJ Case Rep | pages= | pmc= | pmid=22778455 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22778455 }} </ref>
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| *[[Amiodarone]]
| | ==[[Junctional bradycardia historical perspective|Historical Perspective]]== |
| *[[Amyloidosis]]
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| *[[Andersen cardiodysrhythmic periodic paralysis]]
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| *[[Anthracyclines]]
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| *[[Antiarrhythmic drugs]]
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| *[[Barbiturate]]
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| *[[Berberine]]<ref name="pmid23888197">{{cite journal| author=Cannillo M, Frea S, Fornengo C, Toso E, Mercurio G, Battista S et al.| title=Berberine behind the thriller of marked symptomatic bradycardia. | journal=World J Cardiol | year= 2013 | volume= 5 | issue= 7 | pages= 261-4 | pmid=23888197 | doi=10.4330/wjc.v5.i7.261 | pmc=PMC3722425 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23888197 }} </ref>
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| *[[Beta-blockers]]
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| *[[Brugada syndrome]]
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| *[[Bupivacaine]]
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| *[[Calcium channel blockers]]
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| *[[Carbamazepine]]
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| *[[Cardiac catheterization]]
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| *[[cardiac tumor#heart in lymphomas|Cardiac lymphoma]]
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| *[[Cardiac transplantation]]
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| *[[Cardiac tumor]]
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| *[[Carotid sinus hypersensitivity|Cardioinhibitory syncope]]<ref name="pmid17971422">{{cite journal| author=Mehlsen J, Kaijer MN, Mehlsen AB| title=Autonomic and electrocardiographic changes in cardioinhibitory syncope. | journal=Europace | year= 2008 | volume= 10 | issue= 1 | pages= 91-5 | pmid=17971422 | doi=10.1093/europace/eum237 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17971422 }} </ref>
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| *[[Chagas disease]]
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| *[[Cholinesterase inhibitors]]
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| *[[Cimetidine]]
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| *[[Citalopram]]
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| *[[Clonidine]]
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| *[[Congenital heart disease]]
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| *[[Congestive heart failure]]
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| *[[Coronary artery bypass grafting]]
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| *[[reperfusion injury|Coronary reperfusion therapy]]
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| *[[Diabetic ketoacidosis]]
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| *[[Digoxin]]
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| *[[Dilated cardiomyopathy]]
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| *[[Diltiazem]]<ref name="pmid12101159">{{cite journal| author=Isbister GK| title=Delayed asystolic cardiac arrest after diltiazem overdose; resuscitation with high dose intravenous calcium. | journal=Emerg Med J | year= 2002 | volume= 19 | issue= 4 | pages= 355-7 | pmid=12101159 | doi= | pmc=PMC1725910 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12101159 }} </ref>
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| *[[Diphenhydramine]]
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| *[[Diptheria]]
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| *[[Donepezil]]
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| *[[Edrophonium]]
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| *[[Emery-Dreifuss muscular dystrophy]]
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|
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| | ==[[Junctional bradycardia classification|Classification]]== |
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| {{col-break|width=33%}}
| | ==[[Junctional bradycardia pathophysiology|Pathophysiology]]== |
| *[[Fontan procedure]]
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| *[[Granisetron]]
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| *[[Grayanotoxin]]
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| *[[Guanethidine]]
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| *[[Halothane]]
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| *[[Hashimoto's thyroiditis]]
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| *[[Heart surgery]]
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| *[[Hyperkalemia]]
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| *[[Hypermagnesemia]]
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| *[[Hypertensive heart disease]]
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| *[[Hypertrophic cardiomyopathy]]
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| *[[Hypothermia]]
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| *[[Hypoxia]]
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| *[[Idarubicin]]
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| *[[Idiopathic]]
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| *[[regional anesthesia|Infraclavicular brachial plexus block]]
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| *[[Ischemic heart disease]]
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| *[[Isoprenaline|Isoprenaline infusion]]<ref name="pmid16216767">{{cite journal| author=Brembilla-Perrot B, Muhanna I, Nippert M, Popovic B, Beurrier D, Houriez P et al.| title=Paradoxical effect of isoprenaline infusion. | journal=Europace | year= 2005 | volume= 7 | issue= 6 | pages= 621-7 | pmid=16216767 | doi=10.1016/j.eupc.2005.06.012 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16216767 }} </ref>
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| *[[Jervell and Lange-Nielsen syndrome]]
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| *[[Limb-girdle muscular dystrophy|Limb-girdle muscular dystrophy type 1B (LGMD1B)]]
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| *[[Lithium]]
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| *[[Long QT syndrome]]
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| *[[Lyme disease]]
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| *[[Mepivacaine]]
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| *[[Mesalamine]]
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| *[[Metabolic acidosis]]
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| *[[Methyldopa]]
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| *[[Methylprednisolone]]<ref name="pmid10074612">{{cite journal| author=Guillén EL, Ruíz AM, Bugallo JB| title=Hypotension, bradycardia, and asystole after high-dose intravenous methylprednisolone in a monitored patient. | journal=Am J Kidney Dis | year= 1998 | volume= 32 | issue= 2 | pages= E4 | pmid=10074612 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10074612 }} </ref>
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| *[[Muscular dystrophy]]
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| *[[Myocardial infarction]]
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| *[[Myocardial rupture]]
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| *[[Myocarditis]]
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| *[[Myotonic dystrophy]]
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| *[[Nelfinavir]]<ref name="pmid10476763">{{cite journal| author=Landovitz RJ, Sax PE| title=Symptomatic junctional bradycardia after treatment with nelfinavir. | journal=Clin Infect Dis | year= 1999 | volume= 29 | issue= 2 | pages= 449-50 | pmid=10476763 | doi=10.1086/520237 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10476763 }} </ref>
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| *[[Neostigmine]]
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| *[[Nicorandil]]
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| *[[NSTEMI]]
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| *[[organophosphate|Organophosphorus poisoning]]
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| *[[parathion|Parathion poisoning]]
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| *[[Pericarditis]]
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|
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| | ==[[Junctional bradycardia causes|Causes]]== |
|
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| {{col-break|width=33%}}
| | ==[[Junctional bradycardia differential diagnosis|Differentiating Junctional bradycardia from other Disorders]]== |
| *[[Phenothiazine]]
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| *[[Phenytoin]]
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| *[[Pheochromocytoma]]
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| *[[spider bite#spider venom|Poisonous spider bites]]
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| *[[lung transplantation|Post lung transplantation]]
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| *[[Procainamide]]
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| *[[hypothyroidism|Profound hypothyroidism]]
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| *[[Propafenone]]
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| *[[Propanolol]]
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| *[[Propofol]]
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| *[[pyrethroid|Pyrethroid poisoning]]
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| *[[Pyridostigmine]]
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| *[[Remifentanil]]
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| *[[Reserpine]]
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| *[[Romano-Ward syndrome]]
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| *[[Ropivacaine]]
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| *[[Scleroderma]]
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| *[[Arizona bark scorpion|Scorpion toxin]]
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| *[[Septic shock]]
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| *[[anorexia nervosa|Severe anorexia nervosa]]
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| *[[brain damage|Severe brain injury]]
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| *[[Sick sinus syndrome]]
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| *[[Sinus arrest]]
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| *[[Sinus bradycardia]]
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| *[[Sinoatrial arrest|Sinus node fibrosis]]
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| *[[Sjogren's syndrome]]
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| *[[STEMI]]
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| *[[Tachycardia-bradycardia syndrome]]
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| *[[Tacrine]]
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| *[[Takotsubo cardiomyopathy]]
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| *[[Thiamylal]]
| |
| *[[tilt table testing|Tilt testing]]<ref name="pmid22427080">{{cite journal| author=Zyśko D, Gajek J, Agrawal AK, Rudnicki J| title=[The relevance of junctional rhythm during neurocardiogenic reaction provoked by tilt testing]. | journal=Kardiol Pol | year= 2012 | volume= 70 | issue= 2 | pages= 148-55 | pmid=22427080 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22427080 }} </ref>
| |
| *[[Timolol]]
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| *[[Timothy syndrome]]
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| *[[Tricyclic antidepressants]]
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| *[[Urapidil]]
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| *[[Valvular heart disease]]
| |
| *[[Verapamil]]<ref name="pmid17698788">{{cite journal| author=Cohen AS, Matharu MS, Goadsby PJ| title=Electrocardiographic abnormalities in patients with cluster headache on verapamil therapy. | journal=Neurology | year= 2007 | volume= 69 | issue= 7 | pages= 668-75 | pmid=17698788 | doi=10.1212/01.wnl.0000267319.18123.d3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17698788 }} </ref>
| |
| *[[Small for gestational age|Very low birth weight infants]]
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| {{col-end}}
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|
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|
| ==Epidemiology and Demographics== | | ==[[Junctional bradycardia epidemiology and demographics|Epidemiology and Demographics]]== |
| ===Age===
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| Benign junctional rhythms are common during sleep in both children and athletic young adults.
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|
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|
| ===Gender=== | | ==[[Junctional bradycardia risk factors|Risk Factors]]== |
| Males and females are affected equally.
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|
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|
| ==Natural History, Complications and Prognosis== | | ==[[Junctional bradycardia natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| The natural history and prognosis of the disease depends upon the underlying cause that triggered the junctional escape rhythm.
| |
| A [[junctional escape rhythm]] during sleep is benign in children and young adults.
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|
| |
|
| ==Diagnosis== | | ==Diagnosis== |
| ===Symptoms===
| | [[Junctional bradycardia history and symptoms|History and Symptoms]] | [[Junctional bradycardia_physical_examination|Physical Examination]] | [[Junctional bradycardia laboratory findings|Laboratory Findings]] | [[Junctional bradycardia electrocardiogram|Electrocardiogram]] | [[Junctional bradycardia EKG examples|EKG Examples]] | [[Junctional bradycardia chest x-ray|Chest X Ray]] | [[Junctional bradycardia echocardiography|Echocardiography]] | [[Junctional bradycardia cardiac MRI|Cardiac MRI]] | [[Junctional bradycardia coronary angiography|Coronary Angiography]] |
| Symptoms are more likely if the atrial rate is faster than the junctional rate (if [[AV dissociation]] or [[complete heart block]] is present) as compared with the scenario whereby the junctional rate is faster than the atrial rate. The following symptoms may be present:
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| * [[Dyspnea]]
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| * [[Fatigue]]
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| * [[Lightheadedness]]
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| * [[Palpitations]]
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| * [[Presyncope]]
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| * [[Reduced exercise tolerance]]
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| * [[Syncope]]
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| | |
| ===Physical Examination===
| |
| ====Vitals====
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| =====Pulse=====
| |
| The [[pulse]] is regular at a rate of 40 to 60 beats per minute.
| |
| | |
| ====Neck====
| |
| * [[Cannon a waves]] may be present if there is delayed atrial contraction against a closed [[tricuspid valve]]
| |
| | |
| ===Laboratory Findings===
| |
| Based upon the patient's history and demographics, consideration should be given to checking the following:
| |
| * [[Digoxin]] levels
| |
| * [[Lyme titers]] in patients where the disease is endemic
| |
| | |
| ===Electrocardiography===
| |
| A 12 lead EKG should be obtained to evaluate the rhythm. In so far as it may alter treatment, any co-existing rhythm disturbance that may have precipitated junctional bradycardia should be ascertained such as:
| |
| | |
| * [[AV dissociation]]
| |
| * [[Complete heart block]]
| |
| * [[Digitalis toxicity]]
| |
| * [[Sinus arrest]]
| |
| * [[Sinus bradycardia]]
| |
| * [[ST elevation MI]]
| |
| | |
| * The rate is 40-60 beats per minute.
| |
| * The rate is generally regular.
| |
| * The [[QRS]] complex is narrow.
| |
| * [[Retrograde p waves]] may be present due to retrograde conduction from the AV node. The p waves will be inverted in leads II and III.
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| * The [[p wave]] may be buried within the [[QRS]] complex and may not be discernable.
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| * A slow [[AV nodal reentry tachycardia]] ([[AVNRT]]) should be excluded.
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| ===EKG Examples===
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| Shown below is an EKG with a nodal escape rhythm. Note the lack of P or [[P' wave]]s. Often the P' wave is hidden in the QRS as the nodal escape conducts down to the ventricle and up to the atrium in a fashion such that the QRS and P' wave occur simultaneously.
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| [[File:Nodal escape rhythm1.jpg|center|500px]] | |
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| Copyleft images obtained courtesy of ECGpedia, http://en.ecgpedia.org.
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| ----
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| Example of junctional escape rhythm / junctional bradycardia on telemetry:
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| {{#ev:youtube|S2xnOJfZOPI}}
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| ===Holter / Cardiac Event Monitoring===
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| A cardiac event monitor may be helpful in patients with transient symptoms or [[palpitations]] to exclude other rhythms such as [[ventricular tachycardia]].
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| ===Electrophysiologic Studies===
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| * There is normal conduction in the [[His bundle]], and the His-ventricular interval is normal.
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| * Preceding each [[QRS]], there should be a [[His bundle]] depolarization
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| * AV conduction is variable
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| * VA conduction is variable
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|
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| ==Treatment== | | ==Treatment== |
| ===Acute Management===
| | [[Junctional bradycardia medical therapy|Medical Therapy]] | [[Junctional bradycardia electrical cardioversion|Electrical Cardioversion]] | [[Junctional bradycardia ablation|Ablation]] | [[Junctional bradycardia surgery|Surgery]] | [[Junctional bradycardia primary prevention|Primary Prevention]] | [[Junctional bradycardia secondary prevention|Secondary Prevention]] | [[Junctional bradycardia cost effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Junctional bradycardia future or investigational therapies|Future or Investigational Therapies]] |
| * Avoid drugs that suppress the [[AV node]] as the junctional bradycardia may be the patient's only escape rhythm
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| * Treat symptomatic [[digitalis toxicity]] with [[atropine]] and [[digoxin immune Fab]] ([[Digibind]])
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| ===Asymptomatic Patients===
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| *Among healthy patients with heightened [[vagal tone]], no treatment is necessary
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| ===Symptomatic Patients===
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| * Permanent pacemaker placement in indicated in symptomatic patients with:
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| :* [[Complete heart block]]
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| :* High grade [[AV block]]
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| :* [[Sick sinus syndrome]]
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| ==References== | | ==Case Studies== |
| {{Reflist|2}}
| | [[Junctional bradycardia case study one|Case #1]] |
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| ==Related Chapters== | | ==Related Chapters== |
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| * [[Junctional tachycardia]] | | * [[Junctional tachycardia]] |
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