ECG of the month. Competing rhythms. Accelerated idioventricular rhythm.
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Accelerated Idioventricular Rhythm↗
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[Accelerated idioventricular rhythm].
The term accelerated idioventricular rhythm describes an ectopic ventricular rhythm with 3 or more consecutive ventricular premature beats with a rate faster than the normal ventricular intrinsic escape rate of 30 to 40 beats per minute, but slower than ventricular tachycardia. Accelerated idioventricular rhythm differs from ventricular tachycardia by additional features such as the onset with a long coupling interval, the end by a gradual decrease of the ventricular rate or increase of the sinus rate and, last but not least, by a good prognosis. Clinically, accelerated idioventricular rhythm can occur in any form of structural heart disease and occasionally in adults or children without structural heart disease. Accelerated idioventricular rhythm most often can be seen in patients with coronary artery disease. Its occurrence after thrombolysis during acute myocardial infarction is a marker of successful reperfusion. Since accelerated idioventricular rhythm is usually hemodynamically well tolerated and not associated with malignant ventricular tachycardias; as a rule, no specific treatment other than care of the underlying heart disease is necessary. The present overview discusses electrocardiographic criteria, possible mechanisms, and the clinical significance of accelerated idioventricular rhythms.
Accelerated Idioventricular Rhythm↗
[Unsustained ventricular tachycardia and accelerated idioventricular rhythm--clinical and electrocardiographic features].
OBJECTIVE: To compare clinical and electrocardiographic characteristics of Nonsustained Ventricular Tachycardia (NSVT) and Idioventricular Accelerated Rhythm (IVAR). MATERIAL AND METHODS: We studied 155 patients, 113 men and 42 women, with mean age 54 +/- 14 retrospectively, of these, 108 had NSVT and 47 IVAR. The arrhythmias were defined as follows: NSVT-more than 3 ventricular consecutive beats with an heart rate superior to 110 b/m and lasting less than 30 s.; IVAR-3 or more ventricular consecutive beats with an heart rate equal or superior to 50 and lower than 110 b/m, lasting less than 30 s. We evaluated clinical data (symptoms, functional class and anti-arrhythmic therapy), electrocardiographic data (rhythm, changes in conduction and repolarization) and ventricular function (with ECO, Radionuclide Angiography or Ventriculography). In the Holter recording (ECG-H), we analysed the presence of associated ventricular arrhythmias, their electrocardiographic characteristics (number of episodes, number of beats per episode, previous arrhythmia rate, morfology, regularity) and the relations of the arrhythmia with symptoms. RESULTS: Analysis of underlying pathology showed in both groups, the importance of coronary artery disease (44.5% vs 40%) followed by valvular heart disease (24% vs 27.6%) and cardiomyopathy (22.2% vs 17%) respectively to NSVT and IVAR. Only in the NSVT group there were patients without cardiac pathology (3.6%). Comparing with one control group of our department, this distribution was substantially different (p less than 0.0001). All IVAR episodes were assympthomatic compared with 90% of NSVT. Ventricular premature beats were found in all NSVT patients and in 90% of IVAR patients, and were frequent (greater than 10/h) in 79% and 60%, couplets in 84% and 53% respectively (ns). The previous rate of the arrhythmia was 85.3 +/- 20 b/m in NSVT against 68.7 +/- 14 in IVAR (p less than 0.0001). We found left ventricular disfunction in 60% of NSVT patients and in 63.7% in IVAR patients, being serious in 35% and 39% respectively. The follow-up was of 18.5 months (1-72) and posterior evolution showed 14.8% and 17% of deaths with no relation to the arrhythmia, although in NSVT the number of complexes and episodes were related with the ventricular disfunction (p = 0.02 and p = 0.05). CONCLUSION: Both arrhythmias appeared in patients with similar clinical and arrhythmic setting and identified a population with structural cardiopathy, bad function and poor outcome.
Adult↗
Accelerated idioventricular rhythm detected during elective surgery in a healthy man.
Accelerated idioventricular rhythm (AIVR) is found most commonly in the presence of underlying heart disease. It is characterized by acceleration of a latent pacemaker that normally depolarizes slowly. We describe a 30-year-old man who was found to have episodes of accelerated idioventricular rhythm (AIVR) on cardiac monitoring during elective orthopedic surgery. Noninvasive evaluation including two-dimensional echocardiography was unremarkable. No late potentials were detected on a signal-averaged electrocardiogram. During an exercise tolerance test, AIVR was suppressed as heart rate increased. A 24-h Holter monitor revealed that the AIVR rate was consistently 73-76 beats/min, which appeared whenever the sinus rate slowed to this level. The patient has been asymptomatic, and the rhythm has persisted at least through a 5-month follow-up period.
Accelerated Idioventricular Rhythm↗
[Repeated blackout in a patient with accelerated idioventricular rhythm].
There has been no report that Accelerated Idioventricular rhythm (AIVR) causes a syncope attack. The patient described in this report is very rare because AIVR chronic without any heart diseases has been observed for 13 years, and because it is considered that AIVR is closely associated with his repeated blackouts. A 62-year-old male was admitted to our hospital because of repeated syncopal attacks. He reported that he occasionally felt lightheaded after strenuous lifting and pushing or pulling against resistance. We found that AIVR could produce a remarkable arterial pressure drop partly because of ventricular asynergy and loss of timed atrial contribution. Furthermore, we observed syncopal attacks during Valsalva maneuver and found abnormalities of baroreceptor reflex (Lack of reflex tachycardia and weakened evershoot phenomenon). It is concluded that AIVR is not a benign arrhythmia in this patient because it has been a possible cause of syncope attack due to systemic arterial pressure drop and baroreceptor abnormalities.
Accelerated Idioventricular Rhythm↗
Accelerated idioventricular rhythm in patients without acute myocardial infarction.
Accelerated idioventricular rhythm (AIVR) has been reported in patients with acute myocardial infarction, digitalis excess, and subarachnoid hemorrhage, and in patients with rheumatic, primary myocardial, and hypertensive heart disease. Discovery of AIVR in 2 patients without heart disease led us to review reports from 700 Holter monitor studies. Seven patients without recent myocardial infarction were studied retrospectively. Three of the 7 had no evidence of heart disease; 5 of the 7 had abnormalities of the central nervous system. Examples of AIVR show approximation of the sinus rate and ectopic rate; onset and offset occur abruptly or with sinus rate slowing and fusion beats. One patient remained in AIVR for up to 10 minutes accompanied by retrograde atrial capture. The rhythm's acceleration with exercise suggests that it is under autonomic influence, a phenomenon also seen in CNS stimulation studies in dogs. AIVR occurs infrequently in patients without demonstrable heart disease. Our experience suggests a good prognosis, but further study is needed onthe natural history of AIVR in asymptomatic patients and on the necessity of treatment.
Adult↗
[Accelerated idioventricular rhythm in acute myocardial infarct].
A continuous (for 24 hours) ECG recording on a magnetic tape with its subsequent decodification on a special analyser was performed in 31 patients with acute myocardial infarction during the 1st day of the onset of the disease in order to reveal an accelerated idioventricular rhythm and ventricular tachycardia. An accelerated idioventricular rhythm was found to occur within the 1st and early during the 2nd day of the disease in 29% of the patients. The importance of some factors, that of the sinus rhythm rate in particular, was studied with reference to the development of an accelerated idioventricular rhythm. The causes of its development are discussed, as well as those of its disappearance, interrelationship with ventricular tachycardia, and the prognostic importance of the accelerated idioventricular rhythm recorded throughout a 3-month observation and its place in the differential diagnosis in acute myocardial infarction.
Acute Disease↗
Multiform accelerated idioventricular rhythm in acute myocardial infarction.
The presence of accelerated idioventricular rhythm (AIVR) in its multiform variant in two patients with acute myocardial infarction is described. No difference was noted in the clinical evolution of this arrhythmia and the more commonly observed unifocal AIVR.
Acute Disease↗
Cases from the aerospace medicine residents' teaching file. Case #22. An air traffic controller with syncope and accelerated idioventricular rhythm.
An 18-year-old air traffic controller fainted while running; an asymptomatic accelerated idioventricular rhythm was discovered in the ensuing aeromedical workup. The clinical presentation, ECG diagnosis, and aeromedical disposition of accelerated idioventricular rhythm are discussed.
Adolescent↗
Accelerated idioventricular rhythm: a benign arrhythmia in childhood.
OBJECTIVE: To determine whether accelerated idioventricular rhythm (AIVR) is benign in pediatric patients. METHODS: The records were reviewed of all patients younger than age 15 years who had been diagnosed with a ventricular arrhythmia between 1976 and 1991. RESULTS: AIVR was diagnosed in 12 patients, ages 1 day to 15 years (mean, 8.9 years). In 3 patients the arrhythmia was discovered on ambulatory electrocardiographic monitoring after presentation with syncope or presyncopal symptoms. One patient had palpitations. The remaining diagnoses were made during routine examinations or at postoperative follow-ups for congenital heart disease. The AIVR rate ranged from 90 to 150 beats per minute. The rate was within 10 beats per minute of the preceding sinus rate in 11 patients. Echocardiograms were normal in 8 patients. Two patients had double-outlet right ventricles; 1 had repair of the tetralogy of Fallot; and 1 had abnormal ventricular septal motion. Seven patients were taking antiarrhythmia medication without control of the AIVR at presentation. Patients were followed for a mean of 68.4 months (range, 31 to 191 months). All patients were alive and asymptomatic, with normal activity at the last follow-ups. CONCLUSIONS: Complete resolution of AIVR may not occur. However, AIVR seems to be a benign arrhythmia. Treatment was not effective in controlling the arrhythmia and is likely unnecessary.
Accelerated Idioventricular Rhythm↗
Accelerated idioventricular rhythm in three newborn infants with congenital heart disease.
Accelerated idioventricular rhythm was observed in three newborn infants with congenital heart disease. This ventricular arrhythmia in all of our patients did not alter the clinical features of the congenital heart disease, and it disappeared at the ages of 84 days, 40 days, and 45 days, respectively. This arrhythmia is generally considered to be benign, which also appears to be the case with the newborn infant with congenital heart disease.
Age Factors↗
[Accelerated idioventricular rhythm wih isorhythmic A-V dissociation. An electrophysiological study (author's transl)].
Three cases of accelerated idioventricular rhythm with isorhythmic A-V dissociation are presented. One case was affected by hypertrophic non obstructive myocardiopathy and two cases were affected by coronary heart disease with previous myocardial infarction. In all the cases of the arrhythmia persisted for days or months. By means of the electrophysiological study we could establish that 1) the focus was not protected by entrance block and 2) it was localized in the main branches of the conduction system. In the first case the focus was localized in the right bundle branch, in the second case, it was localized in the anterior fascicle of the left bundle branch and in the third case in the posterior fascicle of the left bundle branch. These electrophysiological characteristics suggest that the arrhythmia was due to increased firing of normal idioventricular pacemakers. On the basis of this electrogenetic interpretation we outline that in our cases the term of accelerated idioventricular rhythm should be preferred to others used in literature such as slow ventricular tachycardia.
Adult↗
Accelerated idioventricular rhythm of infundibular origin in patients with a concealed form of arrhythmogenic right ventricular dysplasia.
Five apparently healthy people (aged 16-47) presented with recurrent episodes of accelerated idioventricular rhythm characterised by left bundle branch block and right axis deviation. Clinical history, physical findings, basic electrocardiogram, chest x ray, and blood tests were within normal limits in all. Holter monitoring, exercise stress test, and electrophysiological study (in three patients) showed that accelerated idioventricular rhythm was mainly bradycardia dependent, easily suppressed by effort and overdrive pacing, and originated from the outflow tract of the right ventricle. The mechanism could be enhanced automaticity. Data from cross sectional echocardiography (in all patients) and from haemodynamic evaluation (in three) identified structural or wall motion abnormalities of the right ventricle or both without appreciable dilatation of the ventricle. Biopsy specimens of the right ventricular endomyocardium showed fibrosis in one patient, fibrosis and fatty infiltration in the second, and pronounced fatty infiltration in the third. These results show that some patients with accelerated idioventricular rhythm have right ventricular abnormalities that are typical of the localised and concealed forms of arrhythmogenic right ventricular dysplasia.
Adolescent↗
Accelerated idioventricular rhythm during flexible fiberoptic bronchoscopy.
We report the case of a patient who developed severe hypoxemia and an unusual arrhythmia, accelerated idioventricular rhythm, during flexible fiberoptic bronchoscopy. Coronary artery disease was subsequently suspected despite an unremarkable history and physical examination, and confirmed by a thallium 201 imaging. The appearance of accelerated idioventricular rhythm during fiberoptic bronchoscopy should raise the possibility of underlying coronary artery disease.
Aged↗
[Accelerated idioventricular rhythm. 2 new cases in children].
Two new cases of idiopathic accelerated idioventricular rhythm are reported in children aged 12 and 16. This is a very rare arrhythmia in childhood with only 12 previously published cases in the medical literature. The prognosis seems to be excellent in all cases which underlines the importance of distinguishing this rhythm from other ventricular arrhythmias observed in childhood.
Adolescent↗
[Accelerated idioventricular rhythm].
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Accelerated Idioventricular Rhythm↗
[Current knowledge and problems of accelerated idioventricular rhythm. Clinical observations and indications for therapy].
The authors report on present knowledge and questions concerning Accelerated Idioventricular Rhythm (AIR). The electrocardiographic characteristics and the supposed electrophysiologic mechanisms are analyzed and compared to ventricular tachycardia (VT). The authors emphasize that AIR is not a single entity: in some cases it may represent an unusual form of VT, in others a separate ventricular arrhythmia.
Electrocardiography↗
Multiform accelerated idioventricular rhythm in acute myocardial infarction: electrocardiographic characteristics and response to verapamil.
Thirteen patients with acute myocardial infarction with multiform accelerated idioventricular rhythm (AIVR) occurring during the first 12 hours of monitoring in the coronary care unit are described. This arrhythmia, similar to the more common uniform AIVR, was intermittent, did not cause hemodynamic compromise, and was not related to more serious ventricular arrhythmias. There was no correlation between the bundle branch block pattern of the multiform AIVR and the electrocardiographic location of the myocardial infarction, but there was a perfect correlation between the frontal plane electrical axis of the multiform AIVR and the electrocardiographic location of the myocardial infarction. The presence of fusion beats between the different forms of AIVR suggests multifocality rather than multiformity. Intravenous verapamil (3 to 5 mg bolus) was administered to 6 patients with multiform AIVR in whom the arrhythmias were persistent enough to allow the evaluation of the effect of verapamil on the arrhythmia. Verapamil caused no change in the rate of AIVR in 1 patient, but in a second patient it decreased the rate by 20 beats/min. In 4 patients, verapamil abolished the arrhythmia: in 2 patients carotid sinus pressure (induced sinus slowing) allowed the emergence of the AIVR at a lower rate, and in the remaining 2 patients the arrhythmia was not observed.
Adult↗