Accelerated Idioventricular Rhythm
(AIVR)
by Dr Ed Burns, last update March 16, 2019
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ECG LIBRARY HOMEPAGE
Accelerated Idioventricular Rhythm (AIVR)
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. Also known as Accelerated Ventricular Rhythm
ECG Features
Regular rhythm.
Rate 50-110 bpm.
Three or more ventricular complexes.
QRS complexes >120ms.
Fusion and capture beats.
Isorhythmic AV dissociation
This refers to AV dissociation with sinus and ventricular complexes occurring at identical rates. This is 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 due to retrograde ventricular impulses. These
ventricular impulses depolarise the AV node, leaving it refractory to incoming sinus impulses (= “interference-dissociation”).
Ventricular Rate
Note the rate of AIVR distinguishes it from others rhythms of similar morphology.
Rates < 50 bpm consistent with a Ventricular Escape Rhythm
Rates > 110 bpm consistent with Ventricular Tachycardia
Causes of Accelerated Idioventricular Rhythm (AIVR)
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 trialed in an attempt to increase sinus rate and AV conduction.
ECG Examples
Example 1a
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
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
Broad complex at 90 bpm.
No visible P waves.
This dysrhythmia occurred following reperfusion from an anterior STEMI.
Related Topics
Ventricular tachycardia
Ventricular escape rhythm
References
Dr Smith’s ECG Blog – AIVR cases
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 [PMC 2803604]
