Accelerated Idioventricular Rhythm (AIVR)

AKA: Accelerated Ventricular Rhythm

Background

  • AIVR results when the rate of an ectopic ventricular pacemaker exceeds that of the sinus node.
  • Often associated with increased vagal tone and decreased sympathetic tone.
  • Proposed mechanism is enhanced automaticity of ventricular pacemaker, although triggered activity may play a role especially in ischaemia and digoxin toxicity.
  • AIVR is classically seen in the reperfusion phase of an acute STEMI, e.g. post thrombolysis.
  • Usually a well-tolerated, benign, self-limiting arrhythmia.

ECG Features

Isorhythmic AV dissociation = AV dissociation with sinus and ventricular complexes occurring at similar rates; in contrast to  complete heart block where the atrial rate is usually faster than the ventricular rate.  Isorhythmic AV dissociation is usually due to functional block at the AV node from retrogradely conducted ventricular impulses (“interference-dissociation”), which leaves the AV node refractory to the anterograde sinus impulses.

Note the rate of AIVR distinguishes it from others rhythms of similar morphology.

Causes

There are multiple causes of AIVR including:

  • Reperfusion phase of an acute myocardial infarction (= most common cause)
  • Beta-sympathomimetics such as isoprenaline or adrenaline
  • Drug toxicity, especially digoxin, cocaine and volatile anaesthetics such as desflurane
  • Electrolyte abnormalities
  • Cardiomyopathy, congenital heart disease, myocarditis
  • Return of spontaneous circulation (ROSC) following cardiac arrest
  • Athletic heart

Management

  • AIVR is a benign rhythm in most settings and does not usually require treatment.
  • Usually self limiting and resolves when sinus rate exceeds that of the ventricular foci.
  • Administration of anti-arrhythmics may cause precipitous haemodynamic deterioration and should be avoided.
  • Treat the underlying cause: e.g. correct electrolytes, restore myocardial perfusion.
  • Patients with low-cardiac-output states (e.g. severe biventricular failure) may benefit from restoration of AV synchrony to restore atrial kick – in this case atropine may be trialled in an attempt to increase sinus rate and AV conduction.

ECG Examples

Example 1a

Accelerated Idioventricular Rhythm

  • Ventricular rhythm at 60 bpm.
  • Multiple sinus capture beats.

Competing sinus and idioventricular pacemakers are present. There is underlying sinus arrhythmia, with sinus capture occurring when the sinus rate exceeds the idioventricular rate.

This patient was a healthy 36-year old marathon runner with presumably very high resting vagal tone causing sinus bradycardia and sinus arrhythmia. 

 

Example 1b

Another ECG from the same patient showing:

  • AIVR at 60 bpm.
  • Isorhythmic AV dissociation with frequent sinus capture beats.
  • A fusion beat.

AIVR showing ventricular complexes (V), capture beat (C), fusion beat (F)

 

Example 2

Accelerated Idioventricular Rhythm

  • Ventricular rhythm at 75 bpm.
  • AV dissociation — a dissociated P wave is seen in the rhythm strip, another in lead aVL. Elsewhere, dissociated P waves cause intermittent deformation of the QRS complexes.
  • The taller left rabbit ear sign is present — there is a notched R wave in V1 with a taller initial R wave; this is highly specific for a ventricular origin of the QRS complexes.

AIVR showing dissociated P waves (circled)

Taller left rabbit ear = ventricular origin of QRS complexes

 

Example 3

Accelerated Idioventricular Rhythm

  • Broad complex at 90 bpm.
  • No visible P waves.

This dysrhythmia occurred following reperfusion from an anterior STEMI. 

 

 

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Related Topics

References

  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.
  • Davis M, Davis P, Ross D. Expert Guide to Sports Medicine, American College of Physicians 2003.
  • Mattu A, Brady W. ECGs for the Emergency Physician 2, BMJ Books 2008.
  • Phibbs, BP. Advanced ECG: Boards and Beyond (2nd Edition), Saunders Elsevier 2006.
  • Riera ARP, Barros RB, de Sousa FD, Baranchuk A. Accelerated Idioventricular Rhythm: History and Chronology of the Main Discoveries. Indian Pacing and Electrophysiology Journal;2010; 10(1):40-48
  • Wagner, GS. Marriott’s Practical Electrocardiography (11th edition), Lippincott Williams & Wilkins 2007.
  • Zimmerman FH. Clinical Electrocardiography: PreTest Self-Assessment and Review, McGraw-Hill 1994.

Further Reading

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