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'''For patient information, click [[Idioventricular rhythm(patient information)|here]]'''
'''For patient information, click [[Idioventricular rhythm(patient information)|here]]'''


{{CMG}}; {{AE}}
{{CMG}}; {{AE}} {{MS}}


{{SK}} IVR
{{SK}} IVR


==Overview==
==Overview==
Normally, the pacemaker of the heart that is responsible for triggering each heart beat (ventricular contraction) is the SA (Sino Atrial) node. However, if the ventricle does not receive triggering signals at a rate high enough, the ventricular myocardium itself becomes the pacemaker (escape rhythm). This is called Idioventricular Rhythm. Ventricular signals are transmitted cell-to-cell between cardiomyocytes and not by the conduction system, creating wide sometimes bizarre QRS complexes(> 0.12 sec). The rate is usually 20-40 bpm. If the rate is >40 bpm, it is called accelerated idioventricular rhythm. The rate of 20-40 is the "intrinsic automaticity" of the ventricular myocardium. It can be regarded as a "backup plan" or "redundancy" built into the body.
Normally, the [[SA node]] is responsible for triggering each heart beat that results in ventricular contraction. However, if the [[ventricle]] does not receive triggering signals at a rate high enough, the ventricular myocardium itself becomes the pacemaker or produces escape beats. This is called idioventricular rhythm.
 
==Pathophysiology==
 
*Idioventricular rhythm originates in the ventricular area and the depolarization wave spreads either partially through the electrical conduction system or completely via direct cell-to-cell transmission.
*Idioventricular rhythm can occur as any of the following mechanisms :
** an escape rhythm
** an increased automaticity of a single ventricular ectopic pacemaker. This increased automaticity may lead to rates that are faster than the intrinsic rate of the upper pacemakers.
* The intrinsic rate in idioventricular rhythm is most commonly between 30 and 50 BPM, but the rhythm can be anywhere from 20 to 50 BPM.  
* The idioventricular complexes will have the morphological characteristics of the ventricular escape complex, two ventricular escape complexes, two ventricular escape complexes with associated AV dissociation or ectopic ventricular complexes.<ref name="isbn0-7637-2246-4">{{cite book |author=Miller, Geoffrey P.; Garcia, Tomas B. |authorlink= |editor= |others= |title=Arrhythmia recognition: the art of interpretation |edition= |language= |publisher=Jones and Bartlett Publishers |location=Boston |year=2004 |origyear= |pages= |quote= |isbn=0-7637-2246-4 |oclc= |doi= |url= |accessdate=}}</ref>


==Causes==
==Causes==
===Life Threatening Causes===
===Life Threatening Causes===
Life-threatening causes include conditions which result in death or permanent disability within 24 hours if left untreated.
Idioventricular rhythm is a life-threatening condition and must be treated as such irrespective of the causes.  Life-threatening conditions can result in death or permanent disability within 24 hours if left untreated.
* [[Acute myocardial infarction]]
 
==Common Causes==
*[[Acute rheumatic fever]]
*[[Amiodarone]]
*[[Beta-blockers]]
*[[Calcium channel blockers]]
*[[Cardiomyopathy]]
*[[Congestive heart failure]]
*[[Diabetic ketoacidosis]]
*[[Digoxin]]
*[[Hyperkalemia]]
*[[Hypermagnesemia]]
*[[Hypertensive heart disease]]
*[[Hypothermia]]
*[[NSTEMI]]
*[[organophosphate|Organophosphate poisoning]]
*[[brain damage|Severe brain injury]]


===Common Causes===
===Causes by Organ System===
===Causes by Organ System===
{|style="width:80%; height:100px" border="1"
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" |'''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[Acute coronary syndrome]], [[acute rheumatic fever]], [[Andersen cardiodysrhythmic periodic paralysis]], [[Brugada syndrome]], [[cardiac tumor]], [[complete heart block]], [[congenital heart disease]], [[congestive heart failure]], [[dilated cardiomyopathy]], [[hypertensive heart disease]], [[hypertrophic cardiomyopathy]], [[ischemic heart disease]], [[Jervell and Lange-Nielsen syndrome]], [[Lev's disease]], [[long QT syndrome]], [[myocardial bridging]], [[myocardial infarction]], [[myocarditis]], [[NSTEMI]], [[pericarditis]], [[Romano-Ward syndrome]], [[STEMI]], [[Timothy syndrome]], [[valvular heart disease]]
|-
|bgcolor="LightSteelBlue"| '''Chemical/Poisoning'''
|bgcolor="Beige"| [[carbamate|Carbamate poisoning]], [[organophosphate|organophosphate poisoning]], [[parathion|parathion poisoning]]
|-
|-bgcolor="LightSteelBlue"
| '''Dental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dermatologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
|bgcolor="Beige"| [[Acetylcholine]], [[amiodarone]], [[anthracyclines]], [[beta-blockers]], [[calcium channel blockers]], [[cholinesterase inhibitors]], [[daunorubicin]], [[digitalis]], [[doxorubicin]], [[edrophonium]], [[epirubicin]], [[idarubicin]], [[neostigmine]], [[procainamide]], [[propafenone]], [[propofol]], [[pyridostigmine]], [[quinidine]], [[tramadol]]
|-
|-bgcolor="LightSteelBlue"
| '''Ear Nose Throat'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Endocrine'''
|bgcolor="Beige"| [[Diabetic ketoacidosis]], [[hyperthyroidism]], [[hypothyroidism|profound hypothyroidism]]
|-
|-bgcolor="LightSteelBlue"
| '''Environmental'''
|bgcolor="Beige"| [[Hypothermia]]
|-
|-bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Genetic'''
|bgcolor="Beige"| [[Andersen cardiodysrhythmic periodic paralysis]], [[Brugada syndrome]], [[congenital heart block]], [[congenital heart disease]], [[Emery-Dreifuss muscular dystrophy]], [[Jervell and Lange-Nielsen syndrome]], [[Kearns-Sayre syndrome]], [[Limb-girdle muscular dystrophy|limb-girdle muscular dystrophy type 1B (LGMD1B)]], [[muscular dystrophy]], [[myotonic dystrophy]], [[Romano-Ward syndrome]], [[Timothy syndrome]]
|-
|-bgcolor="LightSteelBlue"
| '''Hematologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Iatrogenic'''
|bgcolor="Beige"| [[Cardiac catheterization]], [[cardiac resynchronization therapy]], [[cardiac transplantation]], [[coronary artery bypass grafting]], [[heart surgery]], [[hypertrophic cardiomyopathy alcohol septal ablation]], [[regional anesthesia|infraclavicular brachial plexus block]]
|-
|-bgcolor="LightSteelBlue"
| '''Infectious Disease'''
|bgcolor="Beige"| [[Acute rheumatic fever]], [[myocarditis]], [[pericarditis]], [[septic shock]]
|-
|-bgcolor="LightSteelBlue"
| '''Musculoskeletal/Orthopedic'''
|bgcolor="Beige"| [[Muscular dystrophy]], [[myotonic dystrophy]], [[Timothy syndrome]]
|-
|-bgcolor="LightSteelBlue"
| '''Neurologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Nutritional/Metabolic'''
|bgcolor="Beige"| [[Hypermagnesemia]], [[hypocalcemia]], [[metabolic acidosis]]
|-
|-bgcolor="LightSteelBlue"
| '''Obstetric/Gynecologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Oncologic'''
|bgcolor="Beige"| [[Cardiac tumor]]
|-
|-bgcolor="LightSteelBlue"
| '''Ophthalmologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Overdose/Toxicity'''
|bgcolor="Beige"| [[Acetylcholine]], [[amiodarone]], [[anthracyclines]], [[cholinesterase inhibitors]], [[propofol]], [[quinidine]], [[tramadol]]
|-
|-bgcolor="LightSteelBlue"
| '''Psychiatric'''
|bgcolor="Beige"| [[Takotsubo cardiomyopathy]], [[anorexia nervosa|severe anorexia nervosa]]
|-
|-bgcolor="LightSteelBlue"
| '''Pulmonary'''
|bgcolor="Beige"| [[Hypoxia]]
|-
|-bgcolor="LightSteelBlue"
| '''Renal/Electrolyte'''
|bgcolor="Beige"| [[Hyperkalemia]], [[renal failure]]
|-
|-bgcolor="LightSteelBlue"
| '''Rheumatology/Immunology/Allergy'''
|bgcolor="Beige"| [[Acute rheumatic fever]], [[neonatal lupus erythematosus]]
|-
|-bgcolor="LightSteelBlue"
| '''Sexual'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Trauma'''
|bgcolor="Beige"| [[Myocardial contusion]], [[brain damage|severe brain injury]]
|-
|-bgcolor="LightSteelBlue"
| '''Urologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Miscellaneous'''
|bgcolor="Beige"| No underlying causes
|-
|}
===Causes in Alphabetical Order===
===Causes in Alphabetical Order===
{{col-begin|width=80%}}
{{col-break|width=33%}}
*[[Acetylcholine]]
*[[Acute coronary syndrome]]
*[[Acute rheumatic fever]]
*[[Amiodarone]]
*[[Andersen cardiodysrhythmic periodic paralysis]]
*[[Anthracyclines]]
*[[Beta-blockers]]
*[[Brugada syndrome]]
*[[Calcium channel blockers]]
*[[carbamate|Carbamate poisoning]]
*[[Cardiac catheterization]]
*[[Cardiac resynchronization therapy]]
*[[Cardiac transplantation]]
*[[Cardiac tumor]]
*[[Cholinesterase inhibitors]]
*[[Complete heart block]]
*[[Congenital heart disease]]
*[[Congestive heart failure]]
*[[Coronary artery bypass grafting]]
*[[Daunorubicin]]
*[[Diabetic ketoacidosis]]
*[[Digitalis]]
*[[Dilated cardiomyopathy]]
*[[Doxorubicin]]
{{col-break|width=33%}}
*[[Edrophonium]]
*[[Emery-Dreifuss muscular dystrophy]]
*[[Epirubicin]]
*[[Heart surgery]]
*[[Hyperkalemia]]
*[[Hypermagnesemia]]
*[[Hypertensive heart disease]]
*[[Hyperthyroidism]]
*[[Hypertrophic cardiomyopathy]]
*[[Hypertrophic cardiomyopathy alcohol septal ablation]]
*[[Hypocalcemia]]
*[[Hypothermia]]
*[[Hypoxia]]
*[[Idarubicin]]
*[[regional anesthesia|Infraclavicular brachial plexus block]]
*[[Ischemic heart disease]]
*[[Jervell and Lange-Nielsen syndrome]]
*[[Kearns-Sayre syndrome]]
*[[Lev's disease]]
*[[Limb-girdle muscular dystrophy|Limb-girdle muscular dystrophy type 1B (LGMD1B)]]
*[[Long QT syndrome]]
*[[Muscular dystrophy]]
*[[Myocardial bridging]]
*[[Myocardial contusion]]
{{col-break|width=33%}}
*[[Myocardial infarction]]
*[[Myocarditis]]
*[[Myotonic dystrophy]]
*[[Neonatal lupus erythematosus]]
*[[Neostigmine]]
*[[NSTEMI]]
*[[organophosphate|Organophosphate poisoning]]
*[[parathion|Parathion poisoning]]
*[[Pericarditis]]
*[[Procainamide]]
*[[hypothyroidism|Profound hypothyroidism]]
*[[Propafenone]]
*[[Propofol]]
*[[Pyridostigmine]]
*[[Quinidine]]
*[[Renal failure]]
*[[Romano-Ward syndrome]]
*[[anorexia nervosa|Severe anorexia nervosa]]
*[[brain damage|Severe brain injury]]
*[[STEMI]]
*[[Takotsubo cardiomyopathy]]
*[[Timothy syndrome]]
*[[Tramadol]]
*[[Valvular heart disease]]
{{col-end}}
==Differentiating Idioventricular Rhythm from other Diseases==
Below is a table to illustrate some of the similarities and disparities between different ventricular arrhythmias.
{| class="wikitable" font-size="90%"
|- style="text-align:center;background-color:#6EB4EB;"
|+'''An overview of ventricular arrhythmias'''
|-
!
!example
!regularity
!ventricular frequency
!origin
![[AV-dissociation]]
|-
| colspan="8" style="text-align:left;background-color:#cfefcf;" | '''Wide complex (QRS>0.12)'''
|-
! [[Ventricular escape beat|Ventricular escape beat(s)]]
| [[Image:V.escape.png|200px]]<ref name="urlECG ¡V A Pictorial Primer">{{cite web |url=http://www.medicine-on-line.com/html/ecg/e0001en_files/08.htm |title=ECG ¡V A Pictorial Primer |format= |work= |accessdate=}}</ref>
| Irregular
| 1-2 bpm
| Ventricle
| Usually associated with [[AV-dissociation]]
|-
! [[Idioventricular rhythm]]
| [[Image:IVR-EKG.jpg|200px]]<ref name="urlwww.learnekgs.com">{{cite web |url=http://www.learnekgs.com |title=www.learnekgs.com |format= |work= |accessdate=}}</ref>
| Regular (mostly)
| Usually 20-50 bpm
| Ventricle
| Usually associated with [[AV-dissociation]]
|-
! [[Accelerated Idioventricular Rhythm]]
| [[Image:aivr_small.svg|200px]]
| Regular (mostly)
| 50-110 bpm
| Ventricle
| Usually associated with [[AV-dissociation]]
|-
! [[Ventricular Tachycardia]]
| [[Image:vt_small.svg|200px]]
| Regular (mostly) if monomorphic
| 110-250 bpm
| Ventricle
| [[AV-dissociation]]
|-
! [[Ventricular Fibrillation]]
| [[Image:vf_small.svg|200px]]
| Irregular
| 400-600 bpm
| Ventricle
| [[AV-dissociation]]
|-
! [[Ventricular flutter|Ventricular Flutter]]
| [[Image:vflutt_small.svg|200px]]
| Regular
| 150-300 bpm
| Ventricle
| [[AV-dissociation]]
|-
! [[Torsade de Pointes]]
| [[Image:tdp_small.svg|200px]]
| Irregular
| 150-300 bpm
| Ventricle
| [[AV-dissociation]]
|}
<br clear="left"/>


== References ==
== References ==

Latest revision as of 18:21, 3 September 2013

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahmoud Sakr, M.D. [2]

Synonyms and keywords: IVR

Overview

Normally, the SA node is responsible for triggering each heart beat that results in ventricular contraction. However, if the ventricle does not receive triggering signals at a rate high enough, the ventricular myocardium itself becomes the pacemaker or produces escape beats. This is called idioventricular rhythm.

Pathophysiology

  • Idioventricular rhythm originates in the ventricular area and the depolarization wave spreads either partially through the electrical conduction system or completely via direct cell-to-cell transmission.
  • Idioventricular rhythm can occur as any of the following mechanisms :
    • an escape rhythm
    • an increased automaticity of a single ventricular ectopic pacemaker. This increased automaticity may lead to rates that are faster than the intrinsic rate of the upper pacemakers.
  • The intrinsic rate in idioventricular rhythm is most commonly between 30 and 50 BPM, but the rhythm can be anywhere from 20 to 50 BPM.
  • The idioventricular complexes will have the morphological characteristics of the ventricular escape complex, two ventricular escape complexes, two ventricular escape complexes with associated AV dissociation or ectopic ventricular complexes.[1]

Causes

Life Threatening Causes

Idioventricular rhythm is a life-threatening condition and must be treated as such irrespective of the causes. Life-threatening conditions can result in death or permanent disability within 24 hours if left untreated.

Common Causes

Causes by Organ System

Cardiovascular Acute coronary syndrome, acute rheumatic fever, Andersen cardiodysrhythmic periodic paralysis, Brugada syndrome, cardiac tumor, complete heart block, congenital heart disease, congestive heart failure, dilated cardiomyopathy, hypertensive heart disease, hypertrophic cardiomyopathy, ischemic heart disease, Jervell and Lange-Nielsen syndrome, Lev's disease, long QT syndrome, myocardial bridging, myocardial infarction, myocarditis, NSTEMI, pericarditis, Romano-Ward syndrome, STEMI, Timothy syndrome, valvular heart disease
Chemical/Poisoning Carbamate poisoning, organophosphate poisoning, parathion poisoning
Dental No underlying causes
Dermatologic No underlying causes
Drug Side Effect Acetylcholine, amiodarone, anthracyclines, beta-blockers, calcium channel blockers, cholinesterase inhibitors, daunorubicin, digitalis, doxorubicin, edrophonium, epirubicin, idarubicin, neostigmine, procainamide, propafenone, propofol, pyridostigmine, quinidine, tramadol
Ear Nose Throat No underlying causes
Endocrine Diabetic ketoacidosis, hyperthyroidism, profound hypothyroidism
Environmental Hypothermia
Gastroenterologic No underlying causes
Genetic Andersen cardiodysrhythmic periodic paralysis, Brugada syndrome, congenital heart block, congenital heart disease, Emery-Dreifuss muscular dystrophy, Jervell and Lange-Nielsen syndrome, Kearns-Sayre syndrome, limb-girdle muscular dystrophy type 1B (LGMD1B), muscular dystrophy, myotonic dystrophy, Romano-Ward syndrome, Timothy syndrome
Hematologic No underlying causes
Iatrogenic Cardiac catheterization, cardiac resynchronization therapy, cardiac transplantation, coronary artery bypass grafting, heart surgery, hypertrophic cardiomyopathy alcohol septal ablation, infraclavicular brachial plexus block
Infectious Disease Acute rheumatic fever, myocarditis, pericarditis, septic shock
Musculoskeletal/Orthopedic Muscular dystrophy, myotonic dystrophy, Timothy syndrome
Neurologic No underlying causes
Nutritional/Metabolic Hypermagnesemia, hypocalcemia, metabolic acidosis
Obstetric/Gynecologic No underlying causes
Oncologic Cardiac tumor
Ophthalmologic No underlying causes
Overdose/Toxicity Acetylcholine, amiodarone, anthracyclines, cholinesterase inhibitors, propofol, quinidine, tramadol
Psychiatric Takotsubo cardiomyopathy, severe anorexia nervosa
Pulmonary Hypoxia
Renal/Electrolyte Hyperkalemia, renal failure
Rheumatology/Immunology/Allergy Acute rheumatic fever, neonatal lupus erythematosus
Sexual No underlying causes
Trauma Myocardial contusion, severe brain injury
Urologic No underlying causes
Miscellaneous No underlying causes

Causes in Alphabetical Order

Differentiating Idioventricular Rhythm from other Diseases

Below is a table to illustrate some of the similarities and disparities between different ventricular arrhythmias.

An overview of ventricular arrhythmias
example regularity ventricular frequency origin AV-dissociation
Wide complex (QRS>0.12)
Ventricular escape beat(s) [2] Irregular 1-2 bpm Ventricle Usually associated with AV-dissociation
Idioventricular rhythm [3] Regular (mostly) Usually 20-50 bpm Ventricle Usually associated with AV-dissociation
Accelerated Idioventricular Rhythm Regular (mostly) 50-110 bpm Ventricle Usually associated with AV-dissociation
Ventricular Tachycardia Regular (mostly) if monomorphic 110-250 bpm Ventricle AV-dissociation
Ventricular Fibrillation Irregular 400-600 bpm Ventricle AV-dissociation
Ventricular Flutter Regular 150-300 bpm Ventricle AV-dissociation
Torsade de Pointes Irregular 150-300 bpm Ventricle AV-dissociation


References

  1. ↑ Miller, Geoffrey P.; Garcia, Tomas B. (2004). Arrhythmia recognition: the art of interpretation. Boston: Jones and Bartlett Publishers. ISBN 0-7637-2246-4.
  2. ↑ "ECG ¡V A Pictorial Primer".
  3. ↑ "www.learnekgs.com".

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