From the Guidelines
Accelerated junctional rhythm (AJR) should be managed with oral beta blockers as first-line chronic therapy, as they are effective in reducing the proarrhythmic effects and long-term toxicity associated with other agents, as recommended by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1. The diagnosis of AJR is based on the presence of a cardiac arrhythmia originating from the atrioventricular junction, with a heart rate between 70-130 beats per minute.
Key Considerations
- The management of AJR depends on whether the patient is symptomatic and the underlying cause.
- For asymptomatic patients with stable vital signs, observation may be sufficient as the rhythm can be transient.
- For symptomatic patients, treatment should address the underlying cause, which may include electrolyte imbalances, medication effects, or myocardial ischemia.
Treatment Options
- Oral beta blockers, such as metoprolol, are recommended as first-line chronic therapy for AJR, as they are effective in reducing the proarrhythmic effects and long-term toxicity associated with other agents 1.
- Oral diltiazem or verapamil may be reasonable for ongoing management in patients with AJR, as they can suppress junctional tachycardia caused by enhanced automaticity 1.
- Flecainide or propafenone may be reasonable for ongoing management in patients without structural heart disease or ischemic heart disease who have AJR, but their use is limited due to the potential for proarrhythmic effects 1.
- Catheter ablation may be reasonable in patients with AJR when medical therapy is not effective or contraindicated, but it is generally reserved for highly symptomatic patients due to the risk of AV block 1.
Additional Considerations
- Correction of electrolyte abnormalities, such as hypokalemia or hypomagnesemia, is essential in the management of AJR.
- If digoxin toxicity is suspected, the medication should be held and digoxin-specific antibody fragments (Digibind) may be needed in severe cases.
- Atropine can be considered if the rate is too slow and causing symptoms.
From the Research
Diagnosis of Accelerated Junctional Rhythm (AJR)
- AJR can be diagnosed using electrocardiogram (ECG) which shows a rate greater than 55 bpm 2
- The diagnosis of AJR can also be made based on clinical, biological, radiological and histological findings, as seen in a case of light-chain cardiac amyloidosis 3
- In some cases, AJR can be a primary presentation of an underlying condition, such as cardiac amyloidosis or acute myocarditis 3, 4
Treatment of Accelerated Junctional Rhythm (AJR)
- Treatment of AJR depends on the underlying cause, and in some cases, it may resolve on its own, as seen in a case of acute myocarditis 4
- In cases where AJR is caused by an underlying condition such as sinus node dysfunction, treatment may involve implantation of a dual chamber pacemaker 5
- In cases where AJR is caused by cardiac amyloidosis, treatment may involve management of the underlying condition, and early diagnosis and proper management are crucial to improve the prognosis of the disease 3
- In cases where AJR is caused by acute myocarditis, treatment may involve management of the underlying condition, and close monitoring of cardiac enzymes and electrocardiography is necessary 4
Management of Underlying Conditions
- In cases where AJR is caused by an underlying condition, management of the underlying condition is crucial, as seen in cases of cardiac amyloidosis and acute myocarditis 3, 4
- Management of underlying conditions may involve pharmacological treatment, as seen in a case of concealed sinus node dysfunction where atropine was used to diagnose the condition 5
- Management of underlying conditions may also involve catheter ablation, as seen in cases of atrioventricular nodal reentrant tachycardia where accelerated junctional rhythm is a known marker for successful slow pathway ablation sites 6