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Atrioventricular Dissociation Clinical Presentation

  • Author: Chirag M Sandesara, MD; Chief Editor: Jeffrey N Rottman, MD  more...
 
Updated: Dec 18, 2014
 

History

AV dissociation can be asymptomatic, but if symptoms related to AV dissociation are present, they are related to bradycardia, tachycardia, AV dyssynchrony, or loss of atrial "kick" and include the following:

  • Exertional dyspnea
  • Light-headedness
  • Throbbing sensation in neck
  • Palpitations
  • Fatigue, malaise
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Physical

Physical findings are related to bradycardia, tachycardia, AV dyssynchrony, and lack of an atrial kick at least intermittently. They include the following:

  • General appearance - Variable pulse or blood pressure due to the changing relationship between atrial and ventricular contractions
  • Pulse - Pulse volume is variable, with fast or slow rates depending on the underlying cause
  • Blood pressure - Low in ventricular tachycardia
  • Jugular venous pulse - Intermittent cannon a waves are noted when atria and ventricles contract simultaneously; a waves vary as PR interval varies or if the P wave is immediately followed by a QRS
  • Heart sounds: Variable intensity of first heart sound; cyclic increase in intensity of first heart sound as PR interval shortens, climaxed by a very loud sound (bruit de cannon); occurs when ventricular rate exceeds atrial rate and QRS occurs just after P wave
  • Beat-to-beat variation in systolic murmurs
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Causes

Major causes of AV dissociation include ventricular tachycardia,[3] nonparoxysmal junctional tachycardia, escape junctional rhythm, and accelerated idioventricular rhythm.

In nonparoxysmal junctional tachycardia, junctional rhythm/tachycardia occur at a rate faster than the sinus rate, without retrograde atrial capture. This is observed in clinical situations such as digoxin toxicity; sinus bradycardia with escape junctional rhythm; and after cardiac surgery, particularly valve surgery or replacement.

Long postectopic cycles allow escape junctional rhythm.

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Contributor Information and Disclosures
Author

Chirag M Sandesara, MD Virginia Cardiovascular Associates, Cardiac Rhythm Care

Chirag M Sandesara, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians-American Society of Internal Medicine, American Heart Association, American Medical Association, Heart Rhythm Society

Disclosure: Nothing to disclose.

Coauthor(s)

Brian Olshansky, MD Professor Emeritus of Medicine, Department of Internal Medicine, University of Iowa College of Medicine

Brian Olshansky, MD is a member of the following medical societies: American College of Cardiology, Heart Rhythm Society, Cardiac Electrophysiology Society, American Heart Association

Disclosure: Received honoraria from Guidant/Boston Scientific for speaking and teaching; Received honoraria from Medtronic for speaking and teaching; Received consulting fee from Guidant/Boston Scientific for consulting; Received consulting fee from BioControl for consulting; Received consulting fee from Boehringer Ingelheim for consulting; Received consulting fee from Amarin for review panel membership; Received consulting fee from sanofi aventis for review panel membership.

Roger Freedman, MD Director of Clinical Cardiology, Professor, Department of Internal Medicine, Division of Cardiology, University of Utah School of Medicine

Roger Freedman, MD is a member of the following medical societies: American College of Cardiology, Heart Rhythm Society, American College of Physicians, American Heart Association, Phi Beta Kappa, Sigma Xi

Disclosure: Received grant/research funds from St. Jude Medical for other; Received consulting fee from St. Jude Medical for consulting; Received ownership interest from St. Jude Medical for other; Received grant/research funds from Boston Scientific for other; Received consulting fee from Boston Scientific for consulting; Received grant/research funds from Medtronic for other; Received consulting fee from Medtronic for consulting; Received consulting fee from Sorin for consulting.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Marschall S Runge, MD, PhD Charles and Anne Sanders Distinguished Professor of Medicine, Chairman, Department of Medicine, Vice Dean for Clinical Affairs, University of North Carolina at Chapel Hill School of Medicine

Marschall S Runge, MD, PhD is a member of the following medical societies: American Physiological Society, American Society for Clinical Investigation, American Society for Investigative Pathology, Association of American Physicians, Texas Medical Association, Southern Society for Clinical Investigation, American Federation for Clinical Research, Association of Professors of Medicine, Association of Professors of Cardiology, American Association for the Advancement of Science, American College of Cardiology, American College of Physicians-American Society of Internal Medicine, American Federation for Medical Research, American Heart Association

Disclosure: Received honoraria from Pfizer for speaking and teaching; Received honoraria from Merck for speaking and teaching; Received consulting fee from Orthoclinica Diagnostica for consulting.

Chief Editor

Jeffrey N Rottman, MD Professor of Medicine, Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine; Cardiologist/Electrophysiologist, University of Maryland Medical System and VA Maryland Health Care System

Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association, Heart Rhythm Society

Disclosure: Nothing to disclose.

Acknowledgements

Ram C Sharma, MD, MRCP Assistant Professor of Medicine, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Louisville

Ram C Sharma, MD, MRCP is a member of the following medical societies: American Academy of Sleep Medicine, American College of Cardiology, and Royal College of Physicians of the United Kingdom

Disclosure: Nothing to disclose.

References
  1. Braunwald E. Atrioventricular dissociation. Braunwald E, Zipes DP, Libby P, eds. Heart Diseases: A Textbook Of Cardiovascular Medicine. 6th ed. WB Saunders Co: Philadelphia, Pa; 2001.

  2. Wagner GS. Atrioventricular dissociation. Wagner GSS, Marriott HJ, eds. Marriott's Practical Electrocardiography. Baltimore, Md: Williams & Wilkins; 1994. 9th ed:

  3. Oreto G, Smeets JL, Rodriguez LM, et al. Wide complex tachycardia with atrioventricular dissociation and QRS morphology identical to that of sinus rhythm: a manifestation of bundle branch reentry. Heart. 1996 Dec. 76(6):541-7. [Medline].

  4. Ho RT, Pietrasik G, Greenspon AJ. A narrow complex tachycardia with intermittent atrioventricular dissociation: What is the mechanism?. Heart Rhythm. 2014 Nov. 11(11):2116-9. [Medline].

  5. Duffield JS, Jacob AJ, Miller HC. Recurrent, life-threatening atrioventricular dissociation associated with toxoplasma myocarditis. Heart. 1996 Nov. 76(5):453-4. [Medline].

  6. Luzza F, Oreto G. Pseudo-atrioventricular dissociation caused by interpolated ventricular extrasystoles in the presence of dual atrioventricular nodal pathway. Chest. 1994 May. 105(5):1587-9. [Medline].

  7. Ogunlade O, Akintomide AO, Ajayi OE, Eluwole OA. Marked first degree atrioventricular block: an extremely prolonged PR interval associated with atrioventricular dissociation in a young Nigerian man with pseudo-pacemaker syndrome: a case report. BMC Res Notes. 2014 Nov 4. 7:781. [Medline]. [Full Text].

  8. Pick A. A-V dissociation. A proposal for a comprehensive classification and consistent terminology. Am Heart J. 1963 Aug. 66:147-50. [Medline].

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