Junctional Rhythm Treatment & Management

Updated: Nov 27, 2018
  • Author: Sean C Beinart, MD, MSc, FACC, FHRS; Chief Editor: Mikhael F El-Chami, MD  more...
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Approach Considerations

Most of the workup on an otherwise healthy patient can be completed in an outpatient setting. Documentation of the arrhythmia on a rhythm strip is essential to properly diagnose the rhythm and to help exclude other causes.

AV nodal junctional rhythms generally are well tolerated; however, bradycardia for prolonged periods often causes symptoms such as dizziness and presyncope or, rarely, frank syncope in younger patients. Patients with coronary artery disease, those with significant comorbidities, or elderly patients may not tolerate a secondary junctional rhythm well and, in the acute setting, may require intervention such as a pacemaker.

Currently, the choices of treatment strategy include determination of the underlying cause and whether it is a normal physiologic response (ie, that observed in a young athlete) or due to a primary cardiac abnormality such as heart block.


Medical Care

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

  • 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.


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


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. [6]