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'''Cardiovascular'''
'''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[Acute coronary syndrome]], [[acute rheumatic fever]], [[Andersen cardiodysrhythmic periodic paralysis]], [[Brugada syndrome]], [[cardiac tumor#heart in lymphomas|cardiac lymphoma]], [[cardiac tumor]], [[Carotid sinus hypersensitivity|cardioinhibitory syncope]], [[congenital heart disease]], [[congestive heart failure]], [[reperfusion injury|coronary reperfusion therapy]], [[dilated cardiomyopathy]], [[hypertensive heart disease]], [[hypertrophic cardiomyopathy]], [[ischemic heart disease]], [[Jervell and Lange-Nielsen syndrome]], [[long QT syndrome]], [[myocardial infarction]], [[myocardial rupture]], [[myocarditis]], [[NSTEMI]], [[pericarditis]], [[Romano-Ward syndrome]], [[sick sinus syndrome]], [[sinus arrest]], [[sinus bradycardia]], [[sinoatrial arrest|sinus node fibrosis]], [[STEMI]], [[tachycardia-bradycardia syndrome]], [[Timothy syndrome]], [[valvular heart disease]]
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[Acute coronary syndrome]], [[acute rheumatic fever]], [[Andersen cardiodysrhythmic periodic paralysis]], [[Brugada syndrome]], [[cardiac tumor#heart in lymphomas|cardiac lymphoma]], [[cardiac tumor]], [[Carotid sinus hypersensitivity|cardioinhibitory syncope]], [[congenital heart disease]], [[congestive heart failure]], [[reperfusion injury|coronary reperfusion therapy]], [[dilated cardiomyopathy]], [[hypertensive heart disease]], [[hypertrophic cardiomyopathy]], [[ischemic heart disease]], [[Jervell and Lange-Nielsen syndrome]], [[long QT syndrome]], [[myocardial infarction]], [[myocardial rupture]], [[myocarditis]], [[NSTEMI]], [[pericarditis]], [[Romano-Ward syndrome]], [[sick sinus syndrome]], [[sinus arrest]], [[sinus bradycardia]], [[sinus node disease|sinus node fibrosis]], [[STEMI]], [[tachycardia-bradycardia syndrome]], [[Timothy syndrome]], [[valvular heart disease]]
|-
|-
|bgcolor="LightSteelBlue"| '''Chemical/Poisoning'''
|bgcolor="LightSteelBlue"| '''Chemical/Poisoning'''

Revision as of 03:13, 26 August 2013

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mugilan Poongkunran M.B.B.S [2]

Synonyms and keywords: Junctional escape; junctional escape rhythm

Overview

Junctional bradycardia is a slow (40 to 60 beats per minute) narrow complex escape rhythm that originates in the atrioventricular node to compensate for slow or impaired conduction of pacemaker activity in the atrium.

Pathophysiology

Normally, the atrioventricular node (AVN) can generate an escape rhythm of 40-60 beats per minute in case the sinoatrial node (SA node) or atrial pacemakers fail (sinus arrest) or slow (sinus bradycardia) or if there is complete heart block. This junctional escape rhythm generates a normal, narrow QRS complex rhythm at a rate below 60 beats per minute (junctional bradycardia) as the electrical impulses once they are generated are conducted with normal velocity down the usual pathways. Retrograde P waves (i.e. upside down) P waves due to retrograde or backward conduction may or may not be present.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Causes by Organ System

Cardiovascular

Acute coronary syndrome, acute rheumatic fever, Andersen cardiodysrhythmic periodic paralysis, Brugada syndrome, cardiac lymphoma, cardiac tumor, cardioinhibitory syncope, congenital heart disease, congestive heart failure, coronary reperfusion therapy, dilated cardiomyopathy, hypertensive heart disease, hypertrophic cardiomyopathy, ischemic heart disease, Jervell and Lange-Nielsen syndrome, long QT syndrome, myocardial infarction, myocardial rupture, myocarditis, NSTEMI, pericarditis, Romano-Ward syndrome, sick sinus syndrome, sinus arrest, sinus bradycardia, sinus node fibrosis, STEMI, tachycardia-bradycardia syndrome, Timothy syndrome, valvular heart disease
Chemical/Poisoning Berberine, grayanotoxin, organophosphate poisoning, parathion poisoning, poisonous spider bites, pyrethroid poisoning, scorpion toxin
Dental No underlying causes
Dermatologic No underlying causes
Drug Side Effect Acetylcholine, all-trans retinoic acid, amiodarone, anthracyclines, antiarrhythmic drugs, barbiturate, beta-blockers, bupivacaine, calcium channel blockers, carbamazepine, cholinesterase inhibitors, cimetidine, citalopram, clonidine, digitalis, digoxin, diltiazem, diphenhydramine, donepezil, edrophonium, neostigmine, granisetron, guanethidine, halothane, idarubicin, isoprenaline infusion, lithium, mepivacaine, mesalamine, methyldopa, methylprednisolone, nelfinavir, nicorandil, phenothiazine, phenytoin, procainamide, propafenone, propanolol, propofol, pyridostigmine, remifentanil, reserpine, ropivacaine, tacrine, thiamylal, timolol, tricyclic antidepressants, urapidil, verapamil
Ear Nose Throat No underlying causes
Endocrine Diabetic ketoacidosis, Hashimoto's thyroiditis, pheochromocytoma, profound hypothyroidism
Environmental Berberine, hypothermia, poisonous spider bites, scorpion toxin
Gastroenterologic No underlying causes
Genetic Andersen cardiodysrhythmic periodic paralysis, Brugada syndrome, congenital heart disease, Emery-Dreifuss muscular dystrophy, Jervell and Lange-Nielsen syndrome, limb-girdle muscular dystrophy type 1B (LGMD1B), muscular dystrophy, myotonic dystrophy, Romano-Ward syndrome, Timothy syndrome
Hematologic No underlying causes
Iatrogenic Cardiac catheterization, cardiac transplantation, coronary artery bypass grafting, Fontan procedure, heart surgery, infraclavicular brachial plexus block, post lung transplantation, tilt testing
Infectious Disease Acute rheumatic fever, Chagas disease, diptheria, Lyme disease, myocarditis, pericarditis, septic shock
Musculoskeletal/Orthopedic Muscular dystrophy, myotonic dystrophy, Timothy syndrome
Neurologic No underlying causes
Nutritional/Metabolic Hypermagnesemia, metabolic acidosis
Obstetric/Gynecologic Very low birth weight infants
Oncologic Cardiac lymphoma, cardiac tumor, multiple myeloma, pheochromocytoma
Ophthalmologic No underlying causes
Overdose/Toxicity All-trans retinoic acid, amiodarone, barbiturate, digitalis, digoxin, halothane, isoprenaline infusion, lithium, propanolol, cholinesterase inhibitors
Psychiatric Takotsubo cardiomyopathy, severe anorexia nervosa
Pulmonary Hypoxia, post lung transplantation
Renal/Electrolyte Acute renal failure, hyperkalemia
Rheumatology/Immunology/Allergy Acute rheumatic fever, scleroderma
Sexual No underlying causes
Trauma Myocardial rupture, severe brain injury
Urologic No underlying causes
Miscellaneous Amyloidosis, idiopathic

Causes in Alphabetical Order

Epidemiology and Demographics

Age

Benign junctional rhythms are common during sleep in both children and athletic young adults.

Gender

Males and females are affected equally.

Natural History, Complications and Prognosis

The natural history and prognosis of the disease depends upon the underlying cause that triggered the junctional escape rhythm. A junctional escape rhythm during sleep is benign in children and young adults.

Diagnosis

Symptoms

Symptoms are more likely if the atrial rate is faster than the junctional rate (if AV dissociation or complete heart block is present) as compared with the scenario whereby the junctional rate is faster than the atrial rate. The following symptoms may be present:

Physical Examination

Vitals

Pulse

The pulse is regular at a rate of 40 to 60 beats per minute.

Neck

Laboratory Findings

Based upon the patient's history and demographics, consideration should be given to checking the following:

Electrocardiography

A 12 lead EKG should be obtained to evaluate the rhythm. In so far as it may alter treatment, any co-existing rhythm disturbance that may have precipitated junctional bradycardia should be ascertained such as:

  • The rate is 40-60 beats per minute.
  • The rate is generally regular.
  • The QRS complex is narrow.
  • Retrograde p waves may be present due to retrograde conduction from the AV node. The p waves will be inverted in leads II and III.
  • The p wave may be buried within the QRS complex and may not be discernable.
  • A slow AV nodal reentry tachycardia (AVNRT) should be excluded.

EKG Examples

Shown below is an EKG with a nodal escape rhythm. Note the lack of P or P' waves. Often the P' wave is hidden in the QRS as the nodal escape conducts down to the ventricle and up to the atrium in a fashion such that the QRS and P' wave occur simultaneously.

Copyleft images obtained courtesy of ECGpedia, http://en.ecgpedia.org.


Example of junctional escape rhythm / junctional bradycardia on telemetry:

{{#ev:youtube|S2xnOJfZOPI}}

Holter / Cardiac Event Monitoring

A cardiac event monitor may be helpful in patients with transient symptoms or palpitations to exclude other rhythms such as ventricular tachycardia.

Electrophysiologic Studies

  • There is normal conduction in the His bundle, and the His-ventricular interval is normal.
  • Preceding each QRS, there should be a His bundle depolarization
  • AV conduction is variable
  • VA conduction is variable

Treatment

Acute Management

Asymptomatic Patients

  • Among healthy patients with heightened vagal tone, no treatment is necessary

Symptomatic Patients

  • Permanent pacemaker placement in indicated in symptomatic patients with:

References

  1. McGregor A, Hurst E, Lord S, Jones G. "Bradycardia following retinoic acid differentiation syndrome in a patient with acute promyelocytic leukaemia". BMJ Case Rep. doi:10.1136/bcr.02.2012.5848. PMID 22778455.
  2. Cannillo M, Frea S, Fornengo C, Toso E, Mercurio G, Battista S; et al. (2013). "Berberine behind the thriller of marked symptomatic bradycardia". World J Cardiol. 5 (7): 261–4. doi:10.4330/wjc.v5.i7.261. PMC 3722425. PMID 23888197.
  3. Mehlsen J, Kaijer MN, Mehlsen AB (2008). "Autonomic and electrocardiographic changes in cardioinhibitory syncope". Europace. 10 (1): 91–5. doi:10.1093/europace/eum237. PMID 17971422.
  4. Isbister GK (2002). "Delayed asystolic cardiac arrest after diltiazem overdose; resuscitation with high dose intravenous calcium". Emerg Med J. 19 (4): 355–7. PMC 1725910. PMID 12101159.
  5. Brembilla-Perrot B, Muhanna I, Nippert M, Popovic B, Beurrier D, Houriez P; et al. (2005). "Paradoxical effect of isoprenaline infusion". Europace. 7 (6): 621–7. doi:10.1016/j.eupc.2005.06.012. PMID 16216767.
  6. Guillén EL, Ruíz AM, Bugallo JB (1998). "Hypotension, bradycardia, and asystole after high-dose intravenous methylprednisolone in a monitored patient". Am J Kidney Dis. 32 (2): E4. PMID 10074612.
  7. Landovitz RJ, Sax PE (1999). "Symptomatic junctional bradycardia after treatment with nelfinavir". Clin Infect Dis. 29 (2): 449–50. doi:10.1086/520237. PMID 10476763.
  8. Zyśko D, Gajek J, Agrawal AK, Rudnicki J (2012). "[The relevance of junctional rhythm during neurocardiogenic reaction provoked by tilt testing]". Kardiol Pol. 70 (2): 148–55. PMID 22427080.
  9. Cohen AS, Matharu MS, Goadsby PJ (2007). "Electrocardiographic abnormalities in patients with cluster headache on verapamil therapy". Neurology. 69 (7): 668–75. doi:10.1212/01.wnl.0000267319.18123.d3. PMID 17698788.

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