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Junctional Rhythm Treatment & Management

  • Author: Sean C Beinart, MD, FACC, FHRS; Chief Editor: Jeffrey N Rottman, MD  more...
Updated: Dec 30, 2015

Medical Care

The decision to treat a junctional rhythm depends on the underlying cause and the stability of the patient.[5]

  • No pharmacologic therapy is needed for asymptomatic, otherwise healthy individuals with junctional rhythms that result from increased vagal tone.
  • In patients with complete AV block, high-grade AV block, or symptomatic sick sinus syndrome (ie, sinus node dysfunction), a permanent pacemaker may be needed. The junctional rhythm serves as an escape mechanism to maintain the heart rate during periods of bradycardia or asystole and should not be suppressed.
  • Emergency department care can include evaluation of the 12-lead ECG findings, airway protection and oxygenation, and blood pressure support, depending on the cause of the rhythm.
  • If the junctional rhythm is due to digitalis toxicity, then atropine, digoxin immune Fab (Digibind), or both may be necessary. In refractory cases of symptomatic digitalis toxicity that results in junctional tachycardia and causes severe symptoms, then intravenous phenytoin can be used. This should be administered in a monitored setting because of possible hypotension or the need for a pacemaker after resolution of the ectopic junctional rhythm.

Surgical Care

See the list below:

  • If junctional rhythm is due to symptomatic sick sinus syndrome, permanent pacemaker implantation is indicated.
  • If ectopic junctional tachycardia, which usually occurs in the pediatric population, is incessant and symptomatic, then radiofrequency ablation via a percutaneous approach is indicated.


Symptomatic cases may benefit from a consultation with a cardiologist and/or an electrophysiologist to better define the etiology and approach to prevention.

Contributor Information and Disclosures

Sean C Beinart, MD, FACC, FHRS Electrophysiologist, Cardiac Associates, PC

Sean C Beinart, MD, FACC, FHRS is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Medical Association, Heart Rhythm Society

Disclosure: Nothing to disclose.

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.

Steven J Compton, MD, FACC, FACP, FHRS Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals

Steven J Compton, MD, FACC, FACP, FHRS is a member of the following medical societies: American College of Physicians, American Heart Association, American Medical Association, Heart Rhythm Society, Alaska State Medical Association, American College of Cardiology

Disclosure: Nothing to disclose.

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.


The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Jonathan Langberg, MD; Spencer Rosero, MD; Wojciech Zareba, MD, PhD, FACC; and David Huang, MD to the development and writing of this article.

  1. Kim D, Shinohara T, Joung B, et al. Calcium dynamics and the mechanisms of atrioventricular junctional rhythm. J Am Coll Cardiol. 2010 Aug 31. 56(10):805-12. [Medline].

  2. Cools E, Missant C. Junctional ectopic tachycardia after congenital heart surgery. Acta Anaesthesiol Belg. 2014. 65 (1):1-8. [Medline].

  3. Deal BJ, Wolff GS, Gelband H. Current Concepts in Diagnosis and Management of Arrhythmias in Infants and Children. New York, NY: Futura Publishing; 1998. 73-5.

  4. Josephson ME. Clinical Cardiac Electrophysiology. 4th ed. Baltimore, Md: Williams & Wilkins; 2008.

  5. Libby P, Bonow RO, Mann DL, Zipes, DP. Specific arrhythmias: diagnosis and treatment. Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, Pa: WB Saunders; 2007. 640-5.

  6. Daubert JP, Rosero SZ, Corsello A. Tachycardias. Rakel RE, Bope ET, eds. Conn's Current Therapy. New York, NY: WB Saunders; 2001. 286-95.

Junctional bradycardia due to profound sinus node dysfunction. No atrial activity is apparent.
Note the retrograde P waves that precede each QRS complex.
Accelerated junctional rhythm is present in this patient. Note the inverted P waves that precede each QRS complex, with a rate of 115 bpm.
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