eMedicine Specialties > Cardiology > Arrhythmias

Accelerated Idioventricular Rhythm

Author: Nayereh G Pezeshkian, MD, Assistant Professor of Medicine, Division of Cardiology and Electrophysiology, University of California, Davis, School of Medicine
Coauthor(s): Yingbo Yang, MD, PhD, Clinical Assistant Professor of Cardiovascular Medicine, Division of Cardiology, Lawrence J Ellison Ambulatory Care Center, University of California, Davis, Medical Center
Contributor Information and Disclosures

Updated: Apr 13, 2010

Introduction

Background

Accelerated idioventricular rhythm (AIVR) was first described by Thomas Lewis in 1910.1 AIVR is currently defined as an enhanced ectopic ventricular rhythm with at least 3 consecutive ventricular beats, which is faster than normal intrinsic ventricular escape rhythm (≤40 bpm), but slower than ventricular tachycardia (at least 100-120 bpm).1 Importantly, there is rate overlap between AIVR and some slow ventricular tachycardia. AIVR should not be diagnosed solely based on ventricular rate. Other characteristics of AIVR are helpful for its correct diagnosis (see Differentials).

AIVR is generally a transient rhythm, rarely causing hemodynamic instability and rarely requiring treatment. However, misdiagnosis of AIVR as slow ventricular tachycardia or complete heart block can lead to inappropriate therapies with potential complications. AIVR is often a clue to certain underlying conditions, like myocardial ischemia -reperfusion, digoxin toxicity, and cardiomyopathies.2,3,4

Pathophysiology

In most cases, the mechanism of AIVR appears to be related to the enhanced automaticity in His-Purkinje fibers and/or myocardium5 , sometimes accompanied with vagal excess and decreased sympathetic activity.6 Ischemia, reperfusion, hypoxia, drugs, and electrolyte abnormalities can all accelerate the phase 4 action potential depolarization rates in His-Purkinje fiber and myocardium, leading to faster spontaneous cell depolarization (enhanced automaticity).7 When the enhanced automaticity in His-Purkinje fiber or myocardium surpasses that of sinus node, AIVR manifests as the dominant rhythm of the heart. Sinus bradycardia may facilitate the appearance of AIVR.

Under certain conditions such as acute ischemia and digoxin toxicity, triggered activity has been suggested as the mechanism for AIVR.8

Most AIVRs originate from a single focus. Occasionally, in patients with acute myocardial ischemia and myocarditis, AIVR can originate from multiple foci.9,10 The ventricular rate of AIVR is generally between 40 to 100-120 bpm.

Usually, AIVR is hemodynamically well tolerated due to its slow ventricular rate. It is self-limited and resolves as sinus rate surpasses the rate of AIVR. Rarely, AIVR can degenerate into ventricular tachycardia or ventricular fibrillation. In patients with severe myocardial dysfunction, AIVR may lead to hemodynamic instability due to the loss of AV synchrony or relatively rapid ventricular rate.

AIVR in accute myocardial infarction

Clinically, AIVR has been best studied in patients with acute ST-elevation myocardial infarction (STEMI). In the thrombolysis era, AIVR was noted to be a marker of reperfusion.11 However, not all patients with reopened coronary artery have AIVR. In patients with acute myocardial infarction treated with primary percutaneous coronary intervention, the reported incidence of AIVR varied significantly, raging from 15-50%, depending on methods of monitoring.7,12

Recently, studies in patients with STEMI treated with primary percutaneous coronary intervention support that AIVR is a marker of occluded coronary artery reopening, but is not necessarily a marker for complete reperfusion. In fact, AIVR seems to be associated with more extensive myocardial damage and delayed microvascular reperfusion12 , although the mortality rates are similar in patients with and without AIVR.

Frequency

United States

The true prevalence of AIVR is unknown.

International

The true prevalence of AIVR is unknown.

Mortality/Morbidity

In general, AIVR does not significantly affect the patients’ mortality and morbidity.
In a very small retrospective observation study, AIVR was found to be associated with lower 7 days survival in postresuscitation patients.13

Race

No racial preponderance exists.

Sex

Men and women are equally affected.

Age

No age predilection exists.

Clinical

History

History is helpful for identifying the underlying etiology for AIVR. The presence of the following conditions supports a potential diagnosis of AIVR.

  • Most patients with AIVR have chest pain or shortness of breath, symptoms related to myocardial ischemia. They often have recent history of myocardial reperfusion with drugs or coronary artery interventions.
  • Some patients with AIVR have chest discomfort, shortness of breath, peripheral edema, cyanosis, clubbing, symptoms related to cardiomyopathy, myocarditis, and congenital heart diseases.
  • Occasionally, patients with AIVR have history of using digoxin, some anesthetic agents, or illicit drugs such as cocaine.
  • Rarely, AIVR can occur in people without apparent heart disease and no identifiable triggers.

Physical

There are no specific physical findings for AIVR. The following physical signs may be present.

  • Slow (<55 bpm) or fast (>100 bpm) pulse rate.
  • Variable heart sound intensity and cannon A waves related to atrioventricular dissociation.
  • Some irregularity of heart rate/pulse rate due to competing sinus rhythm and AIVR.
  • Rarely, hypotension related to either AV asynchrony or relatively rapid ventricular heart rate during AIVR.

Causes

The AIVR can occur in people with and without apparent heart diseases.14 The most common cause of AIVR is myocardial ischemia-reperfusion. Other causes include the following:

  • Buerger disease15
  • Congenital heart disease16
  • Dilated cardimyopathy4
  • Myocarditis10
  • Drugs: Digoxin toxicity3 , cocaine toxicity17 , and various anesthesia agents18,19
  • Electrolyte abnormality
  • Postresuscitation13

More on Accelerated Idioventricular Rhythm

Overview: Accelerated Idioventricular Rhythm
Differential Diagnoses & Workup: Accelerated Idioventricular Rhythm
Treatment & Medication: Accelerated Idioventricular Rhythm
Follow-up: Accelerated Idioventricular Rhythm
Multimedia: Accelerated Idioventricular Rhythm
References
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References

  1. Grimm W, Marchlinski FE. Accelerated Idioventricular Rhythm and Bidirectional Ventricular Tachycardia. In: Cardiac Electrophysiology: From Cell to Bedside. 4th ed. 2004:700-704.

  2. Goldberg S, Greenspon AJ, Urban PL, Muza B, Berger B, Walinsky P, et al. Reperfusion arrhythmia: a marker of restoration of antegrade flow during intracoronary thrombolysis for acute myocardial infarction. Am Heart J. Jan 1983;105(1):26-32. [Medline].

  3. Castellanos A, Azan L, Bierfield J, Myerburg RJ. Digitalis-induced accelerated idioventricular rhythms: revisited. Heart Lung. Jan-Feb 1975;4(1):104-10. [Medline].

  4. Grimm W, Hoffmann J, Menz V, Schmidt C, Müller HH, Maisch B. Significance of accelerated idioventricular rhythm in idiopathic dilated cardiomyopathy. Am J Cardiol. Apr 1 2000;85(7):899-904, A10. [Medline].

  5. Castellanos A Jr, Lemberg L, Arcebal AG. Mechanisms of slow ventricular tachycardias in acute myocardial infarction. Dis Chest. Dec 1969;56(6):470-6. [Medline].

  6. Bonnemeier H, Ortak J, Wiegand UK, Eberhardt F, Bode F, Schunkert H, et al. Accelerated idioventricular rhythm in the post-thrombolytic era: incidence, prognostic implications, and modulating mechanisms after direct percutaneous coronary intervention. Ann Noninvasive Electrocardiol. Apr 2005;10(2):179-87. [Medline].

  7. Hasin Y, Rogel S. Ventricular rhythms in acute myocardial infarction. Cardiology. 1976;61(3):195-207. [Medline].

  8. Holzmann M, Reutter FW. [Accelerated idioventricular rhythm with second degree v.a.-block and reentry (author's transl)]. Z Kardiol. Jan 1977;66(1):52-4. [Medline].

  9. Sclarovsky S, Strasberg B, Fuchs J, Lewin RF, Arditi A, Klainman E, et al. Multiform accelerated idioventricular rhythm in acute myocardial infarction: electrocardiographic characteristics and response to verapamil. Am J Cardiol. Jul 1983;52(1):43-7. [Medline].

  10. Nakagawa M, Hamaoka K, Okano S, Shiraishi I, Sawada T. Multiform accelerated idioventricular rhythm (AIVR) in a child with acute myocarditis. Clin Cardiol. Dec 1988;11(12):853-5. [Medline].

  11. Hohnloser SH, Zabel M, Kasper W, Meinertz T, Just H. Assessment of coronary artery patency after thrombolytic therapy: accurate prediction utilizing the combined analysis of three noninvasive markers. J Am Coll Cardiol. Jul 1991;18(1):44-9. [Medline].

  12. Terkelsen CJ, Sørensen JT, Kaltoft AK, Nielsen SS, Thuesen L, Bøtker HE, et al. Prevalence and significance of accelerated idioventricular rhythm in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention. Am J Cardiol. Dec 15 2009;104(12):1641-6. [Medline].

  13. Tsai MS, Huang CH, Chen HR, Hsieh CC, Chang WT, Hsu CY, et al. Postresuscitation accelerated idioventricular rhythm: a potential prognostic factor for out-of-hospital cardiac arrest survivors. Intensive Care Med. Sep 2007;33(9):1628-32. [Medline].

  14. Chiale PA, Sicouri SJ, Elizari MV, Rosenbaum MB. Chronic idiopathic idioventricular tachycardia caused by slow response automaticity. Pacing Clin Electrophysiol. Nov 1987;10(6):1371-7. [Medline].

  15. Hsu PC, Lin TH, Su HM, Voon WC, Lai WT, Sheu SH. Frequent accelerated idioventricular rhythm in a young male of Buerger's disease with acute myocardial infarction. Int J Cardiol. Jul 4 2008;127(2):e64-6. [Medline].

  16. Nakagawa M, Yoshihara T, Matsumura A, Fusaoka T, Hamaoka K. Accelerated idioventricular rhythm in three newborn infants with congenital heart disease. Chest. Jul 1993;104(1):322-3. [Medline].

  17. Jonsson S, O'Meara M, Young JB. Acute cocaine poisoning. Importance of treating seizures and acidosis. Am J Med. Dec 1983;75(6):1061-4. [Medline].

  18. Marret E, Pruszkowski O, Deleuze A, Bonnet F. Accelerated idioventricular rhythm associated with desflurane administration. Anesth Analg. Aug 2002;95(2):319-21, table of contents. [Medline].

  19. Chhabra A, Subramaniam R. Sudden appearance of idioventricular rhythm during inhalational induction with halothane in a child with congenital cataract. J Postgrad Med. Oct-Dec 2008;54(4):337-9. [Medline].

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Further Reading

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Keywords

accelerated idioventricular rhythm, AIVR, ventricular arrhythmia, slow ventricular tachycardia, VT, ventricular escape rhythm

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Contributor Information and Disclosures

Author

Nayereh G Pezeshkian, MD, Assistant Professor of Medicine, Division of Cardiology and Electrophysiology, University of California, Davis, School of Medicine
Nayereh G Pezeshkian, MD is a member of the following medical societies: American College of Cardiology, American Society of Echocardiography, and Heart Rhythm Society
Disclosure: Nothing to disclose.

Coauthor(s)

Yingbo Yang, MD, PhD, Clinical Assistant Professor of Cardiovascular Medicine, Division of Cardiology, Lawrence J Ellison Ambulatory Care Center, University of California, Davis, Medical Center
Yingbo Yang, MD, PhD is a member of the following medical societies: American College of Cardiology and Heart Rhythm Society
Disclosure: Nothing to disclose.

Medical Editor

Robert E Fowles, MD, Clinical Professor of Medicine, University of Utah College of Medicine; Consulting Staff, Intermountain Medical Center and LDS Hospital; Director and Consulting Staff, Department of Cardiology, Salt Lake Clinic
Robert E Fowles, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, and American Heart Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Ronald J Oudiz, MD, FACP, FACC, FCCP, Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Liu Center for Pulmonary Hypertension, Division of Cardiology, LA Biomedical Research Institute at Harbor-UCLA Medical Center
Ronald J Oudiz, MD, FACP, FACC, FCCP is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Physicians, American Heart Association, and American Thoracic Society
Disclosure: Actelion Grant/research funds Clinical Trials + honoraria; Encysive Grant/research funds Clinical Trials + honoraria; Gilead Grant/research funds Clinical Trials + honoraria; Pfizer Grant/research funds Clinical Trials + honoraria; United Therapeutics Grant/research funds Clinical Trials + honoraria; Lilly Grant/research funds Clinical Trials + honoraria; LungRx  Clinical Trials + honoraria; Bayer Grant/research funds Consulting

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Jeffrey N Rottman, MD, Professor of Medicine and Pharmacology, Director, Clinical Cardiac Electrophysiology Fellowship Program, Vanderbilt University School of Medicine; Chief, Department of Cardiology, Nashville Veterans Affairs Medical Center
Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association and North American Society of Pacing and Electrophysiology (NASPE)
Disclosure: Nothing to disclose.

 
 
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