Junctional Rhythm Treatment & Management

  • Author: Sean C Beinart, MD, FACC, FHRS; Chief Editor: Jeffrey N Rottman, MD   more...
 
Updated: Dec 15, 2010
 

Medical Care

The decision to treat a junctional rhythm depends on the underlying cause and the stability of the patient.[4]

  • 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.
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Surgical Care

  • 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.
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Consultations

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

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Contributor Information and Disclosures
Author

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, and Heart Rhythm Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Alan D Forker, MD  Professor of Medicine, University of Missouri at Kansas City School of Medicine; Director, Outpatient Lipid Diabetes Research, MidAmerica Heart Institute of St Luke's Hospital

Alan D Forker, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, American Society of Hypertension, and Phi Beta Kappa

Disclosure: Research Grant Grant/research funds Hospital contracts to do research; I am a hospital employee with no personal profit; Speakers Bureau Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

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

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

Disclosure: Nothing to disclose.

Amer Suleman, MD  Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital

Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Chief Editor

Jeffrey N Rottman, MD  Professor of Medicine and Pharmacology, Director, Clinical Cardiac Electrophysiology Fellowship Program, Vanderbilt University School of Medicine; Chief, Department of Cardiology, Nashville Veterans Affairs Medical Center

Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association and North American Society of Pacing and Electrophysiology (NASPE)

Disclosure: Nothing to disclose.

References

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

  2. 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.

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

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

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

 
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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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