PR interval: Difference between revisions
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==Causes of Short PR Interval== | ==Causes of Short PR Interval== | ||
===Life Threatening Causes=== | ===Life Threatening Causes=== | ||
Life-threatening causes include conditions which result in death or permanent disability within 24 hours if left untreated. | Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. | ||
*[[Acute respiratory failure]] | |||
*[[Diabetic ketoacidosis]] | |||
*[[Digitalis toxicity]] | |||
*[[Myocardial infarction]] | |||
*[[Pulmonary embolism]] | |||
===Common Causes=== | ===Common Causes=== | ||
* | *[[Hypertensive heart disease]] | ||
*[[Junctional arrhythmias]] | |||
*[[Wolff-Parkinson-White syndrome]]<ref name="MacKenzie-2005">{{Cite journal | last1 = MacKenzie | first1 = R. | title = Short PR interval. | journal = J Insur Med | volume = 37 | issue = 2 | pages = 145-52 | month = | year = 2005 | doi = | PMID = 16060547 }}</ref> | |||
===Causes by Organ System=== | ===Causes by Organ System=== | ||
{|style="width:80%; height:100px" border="1" | {|style="width:80%; height:100px" border="1" | ||
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*[[Diphtheria]] | *[[Diphtheria]] | ||
*[[Dobutamine]] | *[[Dobutamine]] | ||
*[[Duchenne's muscular dystrophy]] | *[[Duchenne's muscular dystrophy]]<ref name="Perloff-1984">{{Cite journal | last1 = Perloff | first1 = JK. | title = Cardiac rhythm and conduction in Duchenne's muscular dystrophy: a prospective study of 20 patients. | journal = J Am Coll Cardiol | volume = 3 | issue = 5 | pages = 1263-8 | month = May | year = 1984 | doi = | PMID = 6707378 }}</ref> | ||
*[[Ebstein’s anomaly]] | *[[Ebstein’s anomaly]] | ||
{{col-break|width=33%}} | {{col-break|width=33%}} | ||
*[[Emery-Dreifuss muscular dystrophy]] | *[[Emery-Dreifuss muscular dystrophy]] | ||
*[[Ephedrine]] | *[[Ephedrine]] | ||
*[[Fabry disease]] | *[[Fabry disease]]<ref name="Efthimiou-1986">{{Cite journal | last1 = Efthimiou | first1 = J. | last2 = McLelland | first2 = J. | last3 = Betteridge | first3 = DJ. | title = Short PR intervals and tachyarrhythmias in Fabry's disease. | journal = Postgrad Med J | volume = 62 | issue = 726 | pages = 285-7 | month = Apr | year = 1986 | doi = | PMID = 3086855 }}</ref> | ||
*[[Flumazenil]] | *[[Flumazenil]] | ||
*[[Friedreich ataxia]] | *[[Friedreich ataxia]] | ||
| Line 220: | Line 229: | ||
*[[Permanent pacemaker]] | *[[Permanent pacemaker]] | ||
*[[Phenylephrine]] | *[[Phenylephrine]] | ||
*[[Pheochromocytoma]] | *[[Pheochromocytoma]]<ref name="Huang-1984">{{Cite journal | last1 = Huang | first1 = SK. | last2 = Rosenberg | first2 = MJ. | last3 = Denes | first3 = P. | title = Short PR interval and narrow QRS complex associated with pheochromocytoma: electrophysiologic observations. | journal = J Am Coll Cardiol | volume = 3 | issue = 3 | pages = 872-5 | month = Mar | year = 1984 | doi = | PMID = 6693659 }}</ref> | ||
*[[Pneumonia]] | *[[Pneumonia]] | ||
*[[Pompe disease]] | *[[Pompe disease]] | ||
| Line 239: | Line 248: | ||
*[[Valvular heart disease]] | *[[Valvular heart disease]] | ||
*[[Verapamil]] | *[[Verapamil]] | ||
*[[Wolff-Parkinson-White syndrome]] | *[[Wolff-Parkinson-White syndrome]]<ref name="Castellanos-1971">{{Cite journal | last1 = Castellanos | first1 = A. | last2 = Castillo | first2 = CA. | last3 = Agha | first3 = AS. | last4 = Tessler | first4 = M. | title = His bundle electrograms in patients with short P-R intervals, narrow QRS complexes, and paroxysmal tachycardias. | journal = Circulation | volume = 43 | issue = 5 | pages = 667-78 | month = May | year = 1971 | doi = | PMID = 5578843 }}</ref> | ||
{{col-end}} | {{col-end}} | ||
Revision as of 01:20, 23 August 2013
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
The PR interval starts at the beginning of the atrial excitation (beginning of the P wave and ends at the beginning of the ventricular excitation (beginning of the QRS complex. It is termed the PQ interval if a Q wave is present. The PR interval measures the time required for an electrical impulse to travel from the atrial myocardium adjacent to the sinoatrial (SA) node to the ventricular myocardium adjacent to the fibers of the Purkinje network.
The duration of the PR interval is normally from 0.10 to 0.21 s. A major portion of the PR interval reflects the slow conduction of an impulse through the AV node, which is controlled by the balance between the sympathetic and parasympathetic divisions of the autonomic nervous system. Therefore, the PR interval varies with the heart rate, being shorter at faster rates when the sympathetic component predominates, and vice versa. The PR interval tends to increase with age [1] [2];
- In childhood: 0.10 - 0.20 sec
- In adolescence: 0.12 - 0.16 sec
- In adulthood: 0.14 - 0.21 sec
Changes in PR interval
A prolonged PQ interval is a sign of delayed conduction through the atrium and AV node. Pathophysiologically, this can be due to 1st, 2nd or 3rd degree AV block, increased vagal tone [Bezold-Jarisch reflex; described as an eponym for a triad of responses (apnea, bradycardia, and hypotension) following intravenous injection of veratrum alkaloids in experimental animals], or it can be pharmacologically induced.[3] [4]
A short PR interval can be seen in the WPW syndrome in which a faster connection exists between the atria and the ventricles.
- Shortens up to a rate of 140 to 150 beats per minute through a withdrawal of parasympathetic tone [5] [6].
- PR may increase with increasing rate in the presence of digoxin or if the conducting system is diseased.
- If the atria are artificially paced the PR increases as the paced rate increases [7].
- Children have shorter PR intervals (0.11 at 1 year).
- Prolongation can be a normal variant: 67.000 healthy airmen studied and 0.52% found to have a prolonged PR.
80% of the PR prolongations ranged from 0.21 to 0.24 [8]. In a second study 59 of 19.000 (0.31%) airmen had a PR of 0.24 or more [9].
- In healthy middle aged men, a prolongation of the PR in the presence of a normal QRS does not affect prognosis and is not related to ischemic heart disease [10].
- PR prolongation often signifies a delay in the AV node but may reflect intra atrial or His Purkinje disease.
Causes of Short PR Interval
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
- Acute respiratory failure
- Diabetic ketoacidosis
- Digitalis toxicity
- Myocardial infarction
- Pulmonary embolism
Common Causes
Causes by Organ System
Causes in Alphabetical Order
Differential Diagnosis of the Shortened PR Interval:
- AV junctional and low atrial rhythms.
- Wolff Parkinson White syndrome [16]
- Lown Ganong Levine syndrome
- Glycogen storage disease [17]
- Hypertension
- Normal variant
- Fabry's disease
- Pheochromocytoma
Differential Diagnosis of a Prolonged PR Interval
- Beta blocker therapy
- AV block due to coronary artery disease, rheumatic disease
- Hyperthyroidism
- Normal variant
Differential Diagnosis of the Depressed PR Interval:
Additional resources
- ECGpedia: Course for interpretation of ECG
- The whole ECG - A basic ECG primer
- 12-lead ECG library
- Simulation tool to demonstrate and study the relation between the electric activity of the heart and the ECG
- ECG information from Children's Hospital Heart Center, Seattle
- ECG Challenge from the ACC D2B Initiative
- National Heart, Lung, and Blood Institute, Diseases and Conditions Index
- A history of electrocardiography
- EKG Interpretations in infants and children
References
- ↑ Beckwith JR. Grant's clinical electrocardiography. New York: McGraw–Hill, 1970:50.
- ↑ Marriott's Practical Electrocardiography, Wagner G.S., 10th edition, 2001
- ↑ Aviado DM, Guevara Aviado D. The Bezold-Jarisch reflex: A historical perspective of cardiopulmonary reflexes, Ann N Y Acad Sci. 2001 Jun; 940: 48-58
- ↑ Mark AL. The Bezold-Jarisch reflex revisited: clinical implications of inhibitory reflexes originating in the heart. J Am Coll Cardiol. 1983 Jan;1 (1): 90-102.
- ↑ Chou's Electrocardiography in Clinical Practice.
- ↑ Atterhog, J. Electrocardiol. 1977:10,331.
- ↑ Lister,J., Am.J. Cardiol 1965:16,516.
- ↑ Johnson, R, Am. J. Cardiol. 1960:6,153.
- ↑ Manning, G., Am. J. Cardiol.1962:9,558.
- ↑ Erikssen, J.,Clin.Card. 1984:7,6.
- ↑ MacKenzie, R. (2005). "Short PR interval". J Insur Med. 37 (2): 145–52. PMID 16060547.
- ↑ Perloff, JK. (1984). "Cardiac rhythm and conduction in Duchenne's muscular dystrophy: a prospective study of 20 patients". J Am Coll Cardiol. 3 (5): 1263–8. PMID 6707378. Unknown parameter
|month=ignored (help) - ↑ Efthimiou, J.; McLelland, J.; Betteridge, DJ. (1986). "Short PR intervals and tachyarrhythmias in Fabry's disease". Postgrad Med J. 62 (726): 285–7. PMID 3086855. Unknown parameter
|month=ignored (help) - ↑ Huang, SK.; Rosenberg, MJ.; Denes, P. (1984). "Short PR interval and narrow QRS complex associated with pheochromocytoma: electrophysiologic observations". J Am Coll Cardiol. 3 (3): 872–5. PMID 6693659. Unknown parameter
|month=ignored (help) - ↑ Castellanos, A.; Castillo, CA.; Agha, AS.; Tessler, M. (1971). "His bundle electrograms in patients with short P-R intervals, narrow QRS complexes, and paroxysmal tachycardias". Circulation. 43 (5): 667–78. PMID 5578843. Unknown parameter
|month=ignored (help) - ↑ Marriott's Practical Electrocardiography
- ↑ Goldberger's Clinical Electrocardiography