Approach Considerations
Patients with accelerated idioventricular rhythm (AIVR) should be treated mainly for its underlying causes, such as digoxin toxicity, myocardial ischemia, and structure heart diseases. Beta-blockers are often used in patients with myocardial ischemia-reperfusion and cardiomyopathy.
Consultations
A cardiology or electrophysiology consult may be helpful in difficult cases.
Activity
Activity may increase sinus rate and inhibit AIVR in some patients. In others, activity may not be well tolerated during AIVR; therefore, temporary bed rest or atropine therapy is reasonable.
Prevention
Prevention is usually unnecessary due to the benign nature of most AIVR events. Occasionally for patients with significant symptoms and hemodynamic instability, atropine can be used to reduce AIVR recurrence by increasing sinus rate.
Avoiding drugs that cause AIVR is helpful.
Transfer
Transfer to an advanced care facility depends on associated conditions.
Medical Care
Treatment for accelerated idioventricular rhythm (AIVR) does not change the prognosis. The most important therapy for patients with AIVR is to treat the underlying etiology.
AIVR is usually hemodynamically tolerated and self-limited; thus, it rarely requires direct treatment. In fact, the recognition of AIVR and the associated etiology is often critical in avoiding treatment for a confounding diagnosis (such as ventricular tachycardia).
Occasionally, patients may not tolerate AIVR due to (1) loss of atrial-ventricular synchrony, (2) relative rapid ventricular rate, or (3) ventricular tachycardia or ventricular fibrillation degenerated from AIVR (extremely rare). Under these situations, atropine can be used to increase the underlying sinus rate to inhibit AIVR.
Other treatments for AIVR, which include isoproterenol, verapamil, antiarrhythmic drugs such as lidocaine and amiodarone, and atrial overdriving pacing are rarely used today.
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Accelerated Idioventricular Rhythm. 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.
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Accelerated Idioventricular 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.
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Accelerated Idioventricular Rhythm. 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.
