History

History is helpful for identifying the underlying etiology for AIVR. The presence of the following conditions supports a potential diagnosis of AIVR:

Most patients with AIVR have chest pain or shortness of breath, symptoms related to myocardial ischemia. They often have recent history of myocardial reperfusion with drugs or coronary artery interventions.^[16]
Some patients with AIVR have chest discomfort, shortness of breath, peripheral edema, cyanosis, clubbing, symptoms related to cardiomyopathy, myocarditis, and congenital heart diseases.
Occasionally, patients with AIVR have history of using digoxin, some anesthetic agents, or illicit drugs such as cocaine.
Rarely, AIVR can occur in people without apparent heart disease and no identifiable triggers.

Physical

There are no specific physical findings for AIVR. The following physical signs may be present:

Slow (< 55 bpm) or fast (>100 bpm) pulse rate.
Variable heart sound intensity and cannon A waves related to atrioventricular dissociation.
Some irregularity of heart rate/pulse rate due to competing sinus rhythm and AIVR.
Rarely, hypotension related to either AV asynchrony or relatively rapid ventricular heart rate during AIVR.

Causes

The AIVR can occur in people with and without apparent heart diseases.^[17]The most common cause of AIVR is myocardial ischemia-reperfusion. Other causes include the following:

Buerger disease^[18]
Congenital heart disease^[19]
Dilated cardiomyopathy^[4]
Myocarditis^[10]
Drugs: Digoxin toxicity,^[3]cocaine toxicity,^[20]and various anesthesia agents^{[21, 22]}
Electrolyte abnormality
Postresuscitation^[15]

Beach et al reported on the case of a boy aged 4 years who appeared to have developed AIVR from the administration of inhaled albuterol to treat his status asthmaticus.^[23]

Differential Diagnoses

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Castellanos A, Azan L, Bierfield J, Myerburg RJ. Digitalis-induced accelerated idioventricular rhythms: revisited. Heart Lung. 1975 Jan-Feb. 4(1):104-10. [QxMD MEDLINE Link].
Grimm W, Hoffmann J, Menz V, Schmidt C, Muller HH, Maisch B. Significance of accelerated idioventricular rhythm in idiopathic dilated cardiomyopathy. Am J Cardiol. 2000 Apr 1. 85(7):899-904, A10. [QxMD MEDLINE Link].
Castellanos A Jr, Lemberg L, Arcebal AG. Mechanisms of slow ventricular tachycardias in acute myocardial infarction. Dis Chest. 1969 Dec. 56(6):470-6. [QxMD MEDLINE Link].
Bonnemeier H, Ortak J, Wiegand UK, et al. Accelerated idioventricular rhythm in the post-thrombolytic era: incidence, prognostic implications, and modulating mechanisms after direct percutaneous coronary intervention. Ann Noninvasive Electrocardiol. 2005 Apr. 10(2):179-87. [QxMD MEDLINE Link].
Hasin Y, Rogel S. Ventricular rhythms in acute myocardial infarction. Cardiology. 1976. 61(3):195-207. [QxMD MEDLINE Link].
Holzmann M, Reutter FW. [Accelerated idioventricular rhythm with second degree v.a.-block and reentry (author's transl)]. Z Kardiol. 1977 Jan. 66(1):52-4. [QxMD MEDLINE Link].
Sclarovsky S, Strasberg B, Fuchs J, et al. Multiform accelerated idioventricular rhythm in acute myocardial infarction: electrocardiographic characteristics and response to verapamil. Am J Cardiol. 1983 Jul. 52(1):43-7. [QxMD MEDLINE Link].
Nakagawa M, Hamaoka K, Okano S, Shiraishi I, Sawada T. Multiform accelerated idioventricular rhythm (AIVR) in a child with acute myocarditis. Clin Cardiol. 1988 Dec. 11(12):853-5. [QxMD MEDLINE Link].
Hohnloser SH, Zabel M, Kasper W, Meinertz T, Just H. Assessment of coronary artery patency after thrombolytic therapy: accurate prediction utilizing the combined analysis of three noninvasive markers. J Am Coll Cardiol. 1991 Jul. 18(1):44-9. [QxMD MEDLINE Link].
Terkelsen CJ, Sorensen JT, Kaltoft AK, et al. Prevalence and significance of accelerated idioventricular rhythm in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention. Am J Cardiol. 2009 Dec 15. 104(12):1641-6. [QxMD MEDLINE Link].
Delewi R, Remmelink M, Meuwissen M, et al. Acute haemodynamic effects of accelerated idioventricular rhythm in primary percutaneous coronary intervention. EuroIntervention. 2011 Aug. 7(4):467-71. [QxMD MEDLINE Link].
Hingorani P, Karnad DR, Rohekar P, Kerkar V, Lokhandwala YY, Kothari S. Arrhythmias seen in baseline 24-hour holter ECG recordings in healthy normal volunteers during phase 1 clinical trials. J Clin Pharmacol. 2016 Jul. 56(7):885-93. [QxMD MEDLINE Link].
Tsai MS, Huang CH, Chen HR, et al. Postresuscitation accelerated idioventricular rhythm: a potential prognostic factor for out-of-hospital cardiac arrest survivors. Intensive Care Med. 2007 Sep. 33(9):1628-32. [QxMD MEDLINE Link].
Hoffman I, Zolnick MR, Bunn C. Transient post-reperfusion left bundle branch block and accelerated idioventricular rhythm with paradoxical QRS narrowing. J Electrocardiol. 2014 Sep-Oct. 47(5):705-7. [QxMD MEDLINE Link].
Chiale PA, Sicouri SJ, Elizari MV, Rosenbaum MB. Chronic idiopathic idioventricular tachycardia caused by slow response automaticity. Pacing Clin Electrophysiol. 1987 Nov. 10(6):1371-7. [QxMD MEDLINE Link].
Hsu PC, Lin TH, Su HM, Voon WC, Lai WT, Sheu SH. Frequent accelerated idioventricular rhythm in a young male of Buerger's disease with acute myocardial infarction. Int J Cardiol. 2008 Jul 4. 127(2):e64-6. [QxMD MEDLINE Link].
Nakagawa M, Yoshihara T, Matsumura A, Fusaoka T, Hamaoka K. Accelerated idioventricular rhythm in three newborn infants with congenital heart disease. Chest. 1993 Jul. 104(1):322-3. [QxMD MEDLINE Link].
Jonsson S, O'Meara M, Young JB. Acute cocaine poisoning. Importance of treating seizures and acidosis. Am J Med. 1983 Dec. 75(6):1061-4. [QxMD MEDLINE Link].
Marret E, Pruszkowski O, Deleuze A, Bonnet F. Accelerated idioventricular rhythm associated with desflurane administration. Anesth Analg. 2002 Aug. 95(2):319-21, table of contents. [QxMD MEDLINE Link].
Chhabra A, Subramaniam R. Sudden appearance of idioventricular rhythm during inhalational induction with halothane in a child with congenital cataract. J Postgrad Med. 2008 Oct-Dec. 54(4):337-9. [QxMD MEDLINE Link].
Beach C, Marcuccio E, Beerman L, Arora G. Accelerated idioventricular rhythm in a child with status asthmaticus. Pediatrics. 2015 Aug. 136(2):e527-9. [QxMD MEDLINE Link].
Elizari MV, Conde D, Baranchuk A, Chiale PA. Accelerated idioventricular rhythm unmasking the brugada electrocardiographic pattern. Ann Noninvasive Electrocardiol. 2015 Jan. 20(1):91-3. [QxMD MEDLINE Link].

Media Gallery

AIVR and sinus rhythm: AIVR starts and terminates gradually, competing with sinus rhythm. A possible ventricular fusion beat (arrow) and isoarrhythmic AV dissociation (arrowheads: sinus P waves) are present. During AIVR, ectopic ventricular rate is just faster than sinus rate. AIVR has a wide QRS morphology different from the QRS morphology in sinus rhythm.
AIVR in atrial fibrillation: AIVR starts and terminates gradually, competing with the ventricular capture beats (arrow) from atrial fibrillation. Ventricular fusion beat (arrowhead) is present. AIVR has a wide QRS morphology different from the QRS morphology of ventricular capture beats.
Complete heart block with escaped junctional rhythm: The AV dissociation in complete heart block is not isoarrhythmic AV dissociation, because the atrial rate is much faster than the escaped junctional ventricular rate.

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Author

Nayereh G Pezeshkian, MD Assistant Professor of Medicine, Division of Cardiology and Electrophysiology, University of California, Davis, School of Medicine

Nayereh G Pezeshkian, MD is a member of the following medical societies: American College of Cardiology, American Society of Echocardiography, 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.

Ronald J Oudiz, MD, FACP, FACC, FCCP Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Liu Center for Pulmonary Hypertension, Division of Cardiology, LA Biomedical Research Institute at Harbor-UCLA Medical Center

Ronald J Oudiz, MD, FACP, FACC, FCCP is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Physicians, American Heart Association, American Thoracic Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Actelion, Bayer, Gilead, United Therapeutics<br/>Received research grant from: Actelion, Arena, Gilead, GSK, Liquidia, Reata, United Therapeutics<br/>Received income in an amount equal to or greater than $250 from: Actelion, Complexa, Gilead, Medtronic, Reata, United Therapeutics.

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

Robert E Fowles, MD Clinical Professor of Medicine, University of Utah College of Medicine; Consulting Staff, Intermountain Medical Center and LDS Hospital; Director and Consulting Staff, Department of Cardiology, Salt Lake Clinic

Robert E Fowles, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, and American Heart Association

Disclosure: Nothing to disclose.

Rakesh K Sharma, MD, FACC Adjunct Associate Professor of Medicine and Cardiology; University of Arkansas for Medical Sciences, Medical Center of South Arkansas

Disclosure: Nothing to disclose.

Vibhuti N Singh, MD, MPH, FACC, FSCAI Clinical Assistant Professor, Division of Cardiology, University of South Florida College of Medicine; Director, Cardiology Division and Cardiac Catheterization Lab, Chair, Department of Medicine, Bayfront Medical Center, Bayfront Cardiovascular Associates; President, Suncoast Cardiovascular Research

Vibhuti N Singh is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, and Florida Medical Association

Disclosure: Nothing to disclose.