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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 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 escape rhythm.  This is called idioventricular rhythm.
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==
==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 an escape rhythm, or as 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.
*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===
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.
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===
==Common Causes==
*[[Acute myocardial infarction]]
*[[Acute rheumatic fever]]
*[[Amiodarone]]
*[[Beta-blockers]]
*[[Calcium channel blockers]]
*[[Cardiomyopathy]]
*[[Cardiomyopathy]]
*[[Congestive heart failure]]
*[[Diabetic ketoacidosis]]
*[[Digoxin]]
*[[Digoxin]]
*[[Electric shock]]
*[[Hyperkalemia]]
*[[Hypermagnesemia]]
*[[Hypertensive heart disease]]
*[[Hypothermia]]
*[[Hypothermia]]
*[[Ibutilide]]
*[[NSTEMI]]
*[[Myocardial ischemia]]
*[[organophosphate|Organophosphate poisoning]]
*[[Reperfusion arrhythmia]]
*[[brain damage|Severe brain injury]]


===Causes by Organ System===
===Causes by Organ System===
{|style="width:80%; height:100px" border="1"
{|style="width:80%; height:100px" border="1"
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" |'''Cardiovascular'''
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" |'''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | No underlying causes
|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="LightSteelBlue"| '''Chemical/Poisoning'''
|bgcolor="Beige"| No underlying causes
|bgcolor="Beige"| [[carbamate|Carbamate poisoning]], [[organophosphate|organophosphate poisoning]], [[parathion|parathion poisoning]]
|-
|-
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
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|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
| '''Drug Side Effect'''
|bgcolor="Beige"| No underlying causes
|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"
|-bgcolor="LightSteelBlue"
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|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Endocrine'''
| '''Endocrine'''
|bgcolor="Beige"| No underlying causes
|bgcolor="Beige"| [[Diabetic ketoacidosis]], [[hyperthyroidism]], [[hypothyroidism|profound hypothyroidism]]
|-
|-
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Environmental'''
| '''Environmental'''
|bgcolor="Beige"| No underlying causes
|bgcolor="Beige"| [[Hypothermia]]
|-
|-
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
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|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Genetic'''
| '''Genetic'''
|bgcolor="Beige"| No underlying causes
|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"
|-bgcolor="LightSteelBlue"
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|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Iatrogenic'''
| '''Iatrogenic'''
|bgcolor="Beige"| No underlying causes
|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"
|-bgcolor="LightSteelBlue"
| '''Infectious Disease'''
| '''Infectious Disease'''
|bgcolor="Beige"| No underlying causes
|bgcolor="Beige"| [[Acute rheumatic fever]], [[myocarditis]], [[pericarditis]], [[septic shock]]
|-
|-
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Musculoskeletal/Orthopedic'''
| '''Musculoskeletal/Orthopedic'''
|bgcolor="Beige"| No underlying causes
|bgcolor="Beige"| [[Muscular dystrophy]], [[myotonic dystrophy]], [[Timothy syndrome]]
|-
|-
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
Line 89: Line 103:
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Nutritional/Metabolic'''
| '''Nutritional/Metabolic'''
|bgcolor="Beige"| No underlying causes
|bgcolor="Beige"| [[Hypermagnesemia]], [[hypocalcemia]], [[metabolic acidosis]]
|-
|-
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
Line 97: Line 111:
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Oncologic'''
| '''Oncologic'''
|bgcolor="Beige"| No underlying causes
|bgcolor="Beige"| [[Cardiac tumor]]
|-
|-
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
Line 105: Line 119:
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Overdose/Toxicity'''
| '''Overdose/Toxicity'''
|bgcolor="Beige"| No underlying causes
|bgcolor="Beige"| [[Acetylcholine]], [[amiodarone]], [[anthracyclines]], [[cholinesterase inhibitors]], [[propofol]], [[quinidine]], [[tramadol]]
|-
|-
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Psychiatric'''
| '''Psychiatric'''
|bgcolor="Beige"| No underlying causes
|bgcolor="Beige"| [[Takotsubo cardiomyopathy]], [[anorexia nervosa|severe anorexia nervosa]]
|-
|-
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Pulmonary'''
| '''Pulmonary'''
|bgcolor="Beige"| No underlying causes
|bgcolor="Beige"| [[Hypoxia]]
|-
|-
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Renal/Electrolyte'''
| '''Renal/Electrolyte'''
|bgcolor="Beige"| No underlying causes
|bgcolor="Beige"| [[Hyperkalemia]], [[renal failure]]
|-
|-
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Rheumatology/Immunology/Allergy'''
| '''Rheumatology/Immunology/Allergy'''
|bgcolor="Beige"| No underlying causes
|bgcolor="Beige"| [[Acute rheumatic fever]], [[neonatal lupus erythematosus]]
|-
|-
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
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|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Trauma'''
| '''Trauma'''
|bgcolor="Beige"| No underlying causes
|bgcolor="Beige"| [[Myocardial contusion]], [[brain damage|severe brain injury]]
|-
|-
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
Line 142: Line 156:


===Causes in Alphabetical Order===
===Causes in Alphabetical Order===
*[[Acute myocardial infarction]]
{{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]]
*[[Brugada syndrome]]
*[[Cardiomyopathy]]
*[[Calcium channel blockers]]
*[[Commotio cordis]]
*[[carbamate|Carbamate poisoning]]
*[[Digoxin]]
*[[Cardiac catheterization]]
*[[Electric shock]]
*[[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]]
*[[Hypothermia]]
*[[Ibutilide]]
*[[Hypoxia]]
*[[Idiopathic]]
*[[Idarubicin]]
*[[Myocardial ischemia]]
*[[regional anesthesia|Infraclavicular brachial plexus block]]
*[[Reperfusion arrhythmia]]
*[[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==
==Differentiating Idioventricular Rhythm from other Diseases==
Below is a Venn diagram to illustrate similarities and differences between different ventricular escape rhythms.
Below is a table to illustrate some of the similarities and disparities between different ventricular arrhythmias.
[[image:Idioventricular.escape.Venn.png|600px]]
 
{| 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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