Junctional rhythm | |
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ECG of junctional rhythm | |
Specialty | Cardiology/electrophysiology |
Diagnostic method | ECG |
Treatment | Varies based on underlying cause [1] |
Junctional rhythm also called nodal rhythm [2] describes an abnormal heart rhythm resulting from impulses coming from a locus of tissue in the area of the atrioventricular node (AV node), [3] the "junction" between atria and ventricles.
Under normal conditions, the heart's sinoatrial node (SA node) determines the rate by which the organ beats – in other words, it is the heart's "pacemaker". The electrical activity of sinus rhythm originates in the sinoatrial node and depolarizes the atria. Current then passes from the atria through the atrioventricular node and into the bundle of His, from which it travels along Purkinje fibers to reach and depolarize the ventricles. This sinus rhythm is important because it ensures that the heart's atria reliably contract before the ventricles, ensuring as optimal stroke volume and cardiac output. [4]
In junctional rhythm, however, the sinoatrial node does not control the heart's rhythm – this can happen in the case of a block in conduction somewhere along the pathway described above, or in sick sinus syndrome, or many other situations. [1] When this happens, the heart's atrioventricular node or bundle of His can take over as the pacemaker, starting the electrical signal that causes the heart to beat. [1] [5] Depending on where the rhythm originates in the AV node, the atria can contract before ventricular contraction due to retrograde conduction, during ventricular contraction, or after ventricular contraction. If there is a blockage between the AV node and the SA node, the atria may not contract at all. [6] [7]
Junctional rhythm can be diagnosed by looking at an ECG: it usually presents without a P wave or with an inverted P wave. Retrograde, or inverted, P waves refers to the depolarization from the AV node back towards the SA node. [8]
Junctional bradycardia is a rhythm that still originates in the AV node or bundle of His, but simply beats at a rate less than 40 beats per minute. [9]
Junctional escape rhythm is a rhythm that still originates in the AV node or bundle of His, but beats at the intrinsic automaticity of the AV node, between 40 and 60 beats per minute. [10]
Accelerated junctional rhythm is when the rhythm of emerged impulses is more than 40 to 60 beats per minute, which is the natural range of the junction. It happens in some instances such as digoxin toxicity, and usually has a rate of between 60 and 100 bpm. [11]
Junctional tachycardia is a rhythm that still originates in the AV node or bundle of His, but simply beats at a rate above 100 beats per minute. [1]
The presentation and symptoms a patient can present with are varied and often dependent on the underlying cause of the junctional rhythm. Patient's can be asymptomatic for example, or experience difficulty breathing and chest pain if they have underlying congestive heart failure. Other nonspecific findings include dizziness, fatigue, palpitations, and passing out. This diagnosis is made via ECG. [1] [5]
Anything that impairs the SA node can potentially lead to a junctional rhythm. Some examples below: [1]
The first finding is that junctional rhythms are regular rhythms. This means that the time interval between beats stays constant. The next normal finding is a normal QRS. Since the impulse still travels down the bundle of His, the QRS will not be wide. Junctional rhythms can present with either bradycardia, a normal heart rate, or tachycardia. [9] The most obvious abnormal finding will be abnormal P waves. One of three options can occur: [12]
1. There are no P waves. This is because of either failure of retrograde flow to the atria or the P wave is hidden in the QRS. If the P wave is hidden that implies the atria depolarize at the same time as the ventricles.
2. There are inverted P waves prior to the QRS complex. This is because of retrograde flow to the atria causing depolarization prior to the ventricular contraction. Since the depolarization is occurring in the opposite direction, the P wave deflection is inverted.
3. There are inverted P waves after the QRS complex. This is because of retrograde flow to the atria after ventricular contraction.
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Junctional rhythm is seen equally in men and women, and can be seen intermittently in young children and athletes, especially during sleep. It occurs commonly in patients with sinus node dysfunction. 1/600 cardiology patients over the age of 65 have sinus node dysfunction. [1]
Bradycardia, also called bradyarrhythmia, is a resting heart rate under 60 beats per minute (BPM). While bradycardia can result from various pathologic processes, it is commonly a physiologic response to cardiovascular conditioning or due to asymptomatic type 1 atrioventricular block.
Electrocardiography is the process of producing an electrocardiogram, a recording of the heart's electrical activity through repeated cardiac cycles. It is an electrogram of the heart which is a graph of voltage versus time of the electrical activity of the heart using electrodes placed on the skin. These electrodes detect the small electrical changes that are a consequence of cardiac muscle depolarization followed by repolarization during each cardiac cycle (heartbeat). Changes in the normal ECG pattern occur in numerous cardiac abnormalities, including:
Wolff–Parkinson–White syndrome (WPWS) is a disorder due to a specific type of problem with the electrical system of the heart involving an accessory pathway able to conduct electrical current between the atria and the ventricles, thus bypassing the atrioventricular node. About 60% of people with the electrical problem developed symptoms, which may include an abnormally fast heartbeat, palpitations, shortness of breath, lightheadedness, or syncope. Rarely, cardiac arrest may occur. The most common type of irregular heartbeat that occurs is known as paroxysmal supraventricular tachycardia.
The atrioventricular node or AV node electrically connects the heart's atria and ventricles to coordinate beating in the top of the heart; it is part of the electrical conduction system of the heart. The AV node lies at the lower back section of the interatrial septum near the opening of the coronary sinus, and conducts the normal electrical impulse from the atria to the ventricles. The AV node is quite compact.
The cardiac conduction system transmits the signals generated by the sinoatrial node – the heart's pacemaker, to cause the heart muscle to contract, and pump blood through the body's circulatory system. The pacemaking signal travels through the right atrium to the atrioventricular node, along the bundle of His, and through the bundle branches to Purkinje fibers in the walls of the ventricles. The Purkinje fibers transmit the signals more rapidly to stimulate contraction of the ventricles.
Supraventricular tachycardia (SVT) is an umbrella term for fast heart rhythms arising from the upper part of the heart. This is in contrast to the other group of fast heart rhythms – ventricular tachycardia, which start within the lower chambers of the heart. There are four main types of SVT: atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia (PSVT), and Wolff–Parkinson–White syndrome. The symptoms of SVT include palpitations, feeling of faintness, sweating, shortness of breath, and/or chest pain.
AV-nodal reentrant tachycardia (AVNRT) is a type of abnormal fast heart rhythm. It is a type of supraventricular tachycardia (SVT), meaning that it originates from a location within the heart above the bundle of His. AV nodal reentrant tachycardia is the most common regular supraventricular tachycardia. It is more common in women than men. The main symptom is palpitations. Treatment may be with specific physical maneuvers, medications, or, rarely, synchronized cardioversion. Frequent attacks may require radiofrequency ablation, in which the abnormally conducting tissue in the heart is destroyed.
A bundle branch block is a partial or complete interruption in the flow of electrical impulses in either of the bundle branches of the heart's electrical system.
A right bundle branch block (RBBB) is a heart block in the right bundle branch of the electrical conduction system.
Atrioventricular block is a type of heart block that occurs when the electrical signal traveling from the atria, or the upper chambers of the heart, to ventricles, or the lower chambers of the heart, is impaired. Normally, the sinoatrial node produces an electrical signal to control the heart rate. The signal travels from the SA node to the ventricles through the atrioventricular node. In an AV block, this electrical signal is either delayed or completely blocked. When the signal is completely blocked, the ventricles produce their own electrical signal to control the heart rate. The heart rate produced by the ventricles is much slower than that produced by the SA node.
Premature atrial contraction (PAC), also known as atrial premature complexes (APC) or atrial premature beats (APB), are a common cardiac dysrhythmia characterized by premature heartbeats originating in the atria. While the sinoatrial node typically regulates the heartbeat during normal sinus rhythm, PACs occur when another region of the atria depolarizes before the sinoatrial node and thus triggers a premature heartbeat, in contrast to escape beats, in which the normal sinoatrial node fails, leaving a non-nodal pacemaker to initiate a late beat.
In cardiology, a ventricular escape beat is a self-generated electrical discharge initiated by, and causing contraction of the ventricles of the heart; normally the heart rhythm is begun in the atria of the heart and is subsequently transmitted to the ventricles. The ventricular escape beat follows a long pause in ventricular rhythm and acts to prevent cardiac arrest. It indicates a failure of the electrical conduction system of the heart to stimulate the ventricles.
Lown–Ganong–Levine syndrome (LGL) is a pre-excitation syndrome of the heart. Those with LGL syndrome have episodes of abnormal heart racing with a short PR interval and normal QRS complexes seen on their electrocardiogram when in a normal sinus rhythm. LGL syndrome was originally thought to be due to an abnormal electrical connection between the atria and the ventricles, but is now thought to be due to accelerated conduction through the atrioventricular node in the majority of cases. The syndrome is named after Bernard Lown, William Francis Ganong, Jr., and Samuel A. Levine.
Sinoatrial arrest is a medical condition wherein the sinoatrial node of the heart transiently ceases to generate the electrical impulses that normally stimulate the myocardial tissues to contract and thus the heart to beat. It is defined as lasting from 2.0 seconds to several minutes. Since the heart contains multiple pacemakers, this interruption of the cardiac cycle generally lasts only a few seconds before another part of the heart, such as the atrio-ventricular junction or the ventricles, begins pacing and restores the heart action. This condition can be detected on an electrocardiogram (ECG) as a brief period of irregular length with no electrical activity before either the sinoatrial node resumes normal pacing, or another pacemaker begins pacing. If a pacemaker other than the sinoatrial node is pacing the heart, this condition is known as an escape rhythm. If no other pacemaker begins pacing during an episode of sinus arrest it becomes a cardiac arrest. This condition is sometimes confused with sinoatrial block, a condition in which the pacing impulse is generated, but fails to conduct through the myocardium. Differential diagnosis of the two conditions is possible by examining the exact length of the interruption of cardiac activity. If the next available pacemaker takes over, it is in the following order:
In cardiology, an accessory pathway is an additional electrical connection between two parts of the heart. These pathways can lead to abnormal heart rhythms (arrhythmias) associated with symptoms of palpitations. Some pathways may activate a region of ventricular muscle earlier than would normally occur, referred to as pre-excitation, and this may be seen on an electrocardiogram. The combination of an accessory pathway that causes pre-excitation with arrhythmias is known as Wolff–Parkinson–White syndrome.
A sinoatrial block is a disorder in the normal rhythm of the heart, known as a heart block, that is initiated in the sinoatrial node. The initial action impulse in a heart is usually formed in the sinoatrial node and carried through the atria, down the internodal atrial pathways to the atrioventricular node (AV) node. In normal conduction, the impulse would travel across the bundle of His, down the bundle branches, and into the Purkinje fibers. This would depolarize the ventricles and cause them to contract.
An ectopic pacemaker, also known as ectopic focus or ectopic foci, is an excitable group of cells that causes a premature heart beat outside the normally functioning SA node of the heart. It is thus a cardiac pacemaker that is ectopic, producing an ectopic beat. Acute occurrence is usually non-life-threatening, but chronic occurrence can progress into tachycardia, bradycardia or ventricular fibrillation. In a normal heart beat rhythm, the SA node usually suppresses the ectopic pacemaker activity due to the higher impulse rate of the SA node. However, in the instance of either a malfunctioning SA node or an ectopic focus bearing an intrinsic rate superior to SA node rate, ectopic pacemaker activity may take over the natural heart rhythm. This phenomenon is called an escape rhythm, the lower rhythm having escaped from the dominance of the upper rhythm. As a rule, premature ectopic beats indicate increased myocyte or conducting tissue excitability, whereas late ectopic beats indicate proximal pacemaker or conduction failure with an escape 'ectopic' beat.
Junctional ectopic tachycardia (JET) is a rare syndrome of the heart that manifests in patients recovering from heart surgery. It is characterized by cardiac arrhythmia, or irregular beating of the heart, caused by abnormal conduction from or through the atrioventricular node. In newborns and infants up to 6 weeks old, the disease may also be referred to as His bundle tachycardia or congenital JET.
Arrhythmias, also known as cardiac arrhythmias, are irregularities in the heartbeat, including when it is too fast or too slow. A resting heart rate that is too fast – above 100 beats per minute in adults – is called tachycardia, and a resting heart rate that is too slow – below 60 beats per minute – is called bradycardia. Some types of arrhythmias have no symptoms. Symptoms, when present, may include palpitations or feeling a pause between heartbeats. In more serious cases, there may be lightheadedness, passing out, shortness of breath, chest pain, or decreased level of consciousness. While most cases of arrhythmia are not serious, some predispose a person to complications such as stroke or heart failure. Others may result in sudden death.
Cardiac physiology or heart function is the study of healthy, unimpaired function of the heart: involving blood flow; myocardium structure; the electrical conduction system of the heart; the cardiac cycle and cardiac output and how these interact and depend on one another.
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