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ECG Diagnosis: Accelerated Idioventricular Rhythm


Thomas H Gildea, MD; Joel T Levis, MD, PhD, FACEP, FAAEM

Perm J 2018;22:17-173 [Full Citation]

E-pub: 03/16/2018

Accelerated idioventricular rhythm (AIVR) is a ventricular rhythm consisting of three or more consecutive monomorphic beats, with gradual onset and gradual termination.1,2 AIVR is usually seen during acute myocardial infarction reperfusion (following thrombolytic therapy or percutaneous coronary intervention), and rarely manifests in patients with completely normal hearts or with structural heart disease.2 As percutaneous coronary intervention has become a more common treatment for patients presenting with acute myocardial infarction (versus thrombolytic therapy), the observation of AIVR by Emergency Department physicians has become less common than it was during the thrombolytic era.2 AIVR has also been associated with several drugs (eg, halothane, aconitine, desflurane, cocaine, and digitalis), electrolyte imbalances (eg, hypo- and hyperkalemia), cardiomyopathies, and during the postresuscitation period following cardiac arrest.2-5

Electrocardiogram characteristics of AIVR include a regular rhythm, 3 or more ventricular complexes with QRS complex > 120 milliseconds, a ventricular rate between 50 beats/min and 110 beats/min, and occasional fusion or capture beats. This rhythm has two postulated, possibly coexisting causes.6 First, the sinoatrial or atrioventricular node may suffer structural damage with depression of nodal automaticity potentiated by enhanced vagal tone. Second, an abnormal ectopic focus within the ventricle may assume the role of dominant pacemaker.6 The ventricular ectopic focus manifests when the sinus rate slows down (below the ectopic focus) or when the ectopic focus accelerates above the intrinsic rate by 30 beats/min to 40 beats/min.2 When both discharge rates (sinus and ectopic focus) are similar, isorhythmic dissociation, fusion beats, and capture beats can be seen.

AIVR is usually a benign and well-tolerated arrhythmia.2 Most cases of AIVR will require no immediate treatment for this dysrhythmia, because AIVR is usually self-limiting and resolves when the sinus rate exceeds that of the ventricular foci.6 Administration of antiarrhythmics to patients with AIVR may cause precipitous hemodynamic deterioration and should be avoided.6 In cases of AIVR, remember to treat the underlying cause: For example, restore myocardial perfusion (thrombolytics or percutaneous coronary intervention), or correct electrolyte abnormalities. Patients with low cardiac-output states (eg, severe biventricular failure) may benefit from restoration of atrioventricular synchrony to restore atrial kick. In cases of low cardiac output associated with AIVR, atropine may be used in an attempt to increase sinus rate and atrioventricular conduction.7

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Disclosure Statement

The author(s) have no conflicts of interest to disclose.


Kathleen Louden, ELS, of Louden Health Communications provided editorial assistance.

How to Cite this Article

Gildea TH, Levis JT. ECG diagnosis: Accelerated idioventricular rhythm. Perm J 2018;22:17-173. DOI: https://doi.org/10.7812/TPP/17-173

1.    Rothfeld EL, Zucker IR, Parsonnet V, Alinsonorin CA. Idioventricular rhythm in acute myocardial infarction. Circulation 1968 Feb 1;37(2):203-9. DOI: https://doi.org/10.1161/01.CIR.37.2.203.
    2.    Riera AR, Barros RB, de Sousa FD, Baranchuk A. Accelerated intraventricular rhythm: History and chronology of the main discoveries. Indian Pacing and Electrophysiol J 2010 Jan 7;10(1):40-8.
    3.    Moroz VM, Lipnitskii TN. Study of pathogenesis of ventricular arrhythmia in experimental rats by separation of sinus and ventricular substitutional rhythms. Bull Exp Biol Med 2006 Apr;141(4):400-3. DOI: https://doi.org/10.1007/s10517-006-0182-4.
    4.    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. DOI: https://doi.org/10.1007/s00134-007-0633-z.
    5.    Grimm W, Hoffmann J, Menz V, Schmidt C, Müller HH, Maisch B. Significance of accelerated idioventricular rhythm in idiopathic dilated cardiomyopathy. Am J Cardiol 2000 Apr 1;85(7):899-904. DOI: https://doi.org/10.1016/s0002-9149(99)00892-9.
    6.    Perron AD, Sweeney T. Arrhythmic complications of acute coronary syndromes. Emerg Med Clin North Am 2005 Nov;23(4):1065-82. DOI: https://doi.org/10.1016/j.emc.2005.07.002.
    7.    Scheinman MM, Thorburn D, Abbott JA. Use of atropine in patients with acute myocardial infarction and sinus bradycardia. Circulation 1975 Oct;52(4):627-33. DOI: https://doi.org/10.1161/01.cir.52.4.627.


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