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Atrioventricular junctional rhythm
Other Resources UpToDate PubMed

Atrioventricular junctional rhythm

Contributors: Young Ju Esther Lee MD, Ryan Hoefen MD, PhD
Other Resources UpToDate PubMed


Atrioventricular (AV) junctional rhythm is an arrhythmia that originates from the AV node or bundle of His, or His bundle. In sinus rhythm, the heart rate originates in the sinoatrial (SA) node, traveling to the AV node and the bundle of His toward the ventricles. In AV junctional rhythm, the AV node or His bundle takes over, and/or the electrical activity of the SA node is less than the automaticity of the AV node. A junctional rhythm is normally slow, less than 60 beats per minute. If it is faster, it is referred to as an accelerated junctional rhythm. Because electrical activity still follows the normal conduction system (through His-Purkinje), the QRS complex is usually narrow, except in patients with a bundle branch block at baseline. P waves are often seen, although they may be inverted and can be before, after, or buried within the QRS complex due to retrograde conduction through the atria.

Terminology of the types of junctional rhythms depends on the rate. All rhythms will be regular and narrow-complex unless there is baseline intraventricular conduction delay.
  • Junctional bradycardia: < 40 beats per minute
  • Junctional escape rhythm: 40-60 beats per minute
  • Accelerated junctional rhythm: 60-100 beats per minute
  • Junctional tachycardia: > 100 beats per minute
Etiologies include sick sinus syndrome, collagen vascular diseases, neuromuscular disorders, amyloidosis, Lyme carditis, rheumatic fever, ischemic heart disease, acute myocardial infarction, coronary artery disease, inherited channelopathy, sleep apnea, hypothyroidism, and pericarditis / myocarditis. Iatrogenic and medication-related causes include beta blockers, calcium channel blockers, digoxin, hyperkalemia, cannabinoids, chest trauma, radiation therapy, and vasovagal stimulation such as endotracheal suctioning.

Junctional rhythms are more common among those with sinus node dysfunction. Athletes and young children may also exhibit a junctional rhythm during sleep. Congenital ectopic junctional tachycardia is a rare disorder that is often refractory to medical therapy.


I49.8 – Other specified cardiac arrhythmias

11849007 – AV junctional rhythm

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • Second-degree atrioventricular block
  • Complete atrioventricular block
  • Atrioventricular nodal reentry tachycardia
  • Atrioventricular reentry tachycardia
  • Sinus tachycardia
  • Atrial escape rhythm
  • Sinus node dysfunction
  • Sinus bradycardia
  • Digitalis toxicity
  • Lyme carditis (see Lyme disease)

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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Last Reviewed:07/01/2020
Last Updated:07/26/2020
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Atrioventricular junctional rhythm
A medical illustration showing key findings of Atrioventricular junctional rhythm : Dizziness, Heart palpitations, Syncope
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