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Copyright (c) 2025 Thallab Almutairi, Baneen Ali Eassa, Samira Dhaifullah Ali Mudarba, Muneera Alhalw Alanezy, Nawal Lahiq Salman Alwadani, Mohammed Ahmed Alzahrani, Roza Saeed Alamoudi, Roaa Mahmoud Aljezani, Salwa Osamh Rashed, Norah Hussain Harthi, Bashair Bder Qodsi, Shaimaa Mahdi Banaja, Salem Mohammed Saed Almlallali
This work is licensed under a Creative Commons Attribution 4.0 International License.
Junctional Rhythm: Cardiac Conduction Abnormalities and Clinical Implications in Nursing
Corresponding Author(s) : Thallab Almutairi
Saudi Journal of Medicine and Public Health, Vol. 2 No. 2 (2025)
Abstract
Background: Junctional rhythm is a cardiac conduction abnormality that arises when the sinoatrial (SA) node fails to function effectively, allowing the atrioventricular (AV) junction to assume pacemaker activity. Although often benign, junctional rhythms may indicate significant underlying cardiac or systemic pathology and are frequently encountered in clinical nursing practice.
Aim: This article aims to provide a comprehensive overview of junctional rhythm, focusing on its etiology, pathophysiology, clinical presentation, evaluation, management, and nursing implications.
Methods: A narrative review approach was used to synthesize current evidence regarding junctional rhythm. The article integrates anatomical, electrophysiological, clinical, and nursing perspectives, drawing from established cardiology and nursing literature to enhance clinical applicability.
Results: Junctional rhythm occurs due to suppression or failure of SA node activity and may present at varying heart rates, including junctional bradycardia, escape rhythm, accelerated junctional rhythm, and junctional tachycardia. Clinical manifestations range from asymptomatic findings to dizziness, syncope, and hemodynamic instability, depending on heart rate and underlying cause. Electrocardiography remains the cornerstone of diagnosis, while management primarily targets correction of reversible etiologies. In severe or persistent cases, pharmacologic therapy or pacemaker implantation may be required.
Conclusion: Junctional rhythm represents both a protective cardiac mechanism and a potential marker of serious underlying disease. Accurate recognition and appropriate management are essential to prevent complications and optimize patient outcomes.
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- Spodick DH. Normal sinus heart rate: sinus tachycardia and sinus bradycardia redefined. Am Heart J. 1992 Oct;124(4):1119-21.
- Thery C, Gosselin B, Lekieffre J, Warembourg H. Pathology of sinoatrial node. Correlations with electrocardiographic findings in 111 patients. Am Heart J. 1977 Jun;93(6):735-40.
- Dobrzynski H, Anderson RH, Atkinson A, Borbas Z, D'Souza A, Fraser JF, Inada S, Logantha SJ, Monfredi O, Morris GM, Moorman AF, Nikolaidou T, Schneider H, Szuts V, Temple IP, Yanni J, Boyett MR. Structure, function and clinical relevance of the cardiac conduction system, including the atrioventricular ring and outflow tract tissues. Pharmacol Ther. 2013 Aug;139(2):260-88.
- Van der Hauwaert LG, Stroobandt R, Verhaeghe L. Arterial blood supply of the atrioventricular node and main bundle. Br Heart J. 1972 Oct;34(10):1045-51.
- Pejković B, Krajnc I, Anderhuber F, Kosutić D. Anatomical aspects of the arterial blood supply to the sinoatrial and atrioventricular nodes of the human heart. J Int Med Res. 2008 Jul-Aug;36(4):691-8.
- Chua K, Upadhyay GA, Lee E, Aziz Z, Beaser AD, Ozcan C, Broman M, Nayak HM, Tung R. High-resolution mapping of the triangle of Koch: Spatial heterogeneity of fast pathway atrionodal connections. Heart Rhythm. 2018 Mar;15(3):421-429.
- Semelka M, Gera J, Usman S. Sick sinus syndrome: a review. Am Fam Physician. 2013 May 15;87(10):691-6.
- Trappe HJ. Tachyarrhythmias, bradyarrhythmias and acute coronary syndromes. J Emerg Trauma Shock. 2010 Apr;3(2):137-42.
- Silvestri NJ, Ismail H, Zimetbaum P, Raynor EM. Cardiac involvement in the muscular dystrophies. Muscle Nerve. 2018 May;57(5):707-715.
- Patel P, Kelschenbach K. Case of Junctional Rhythm in the Setting of Acute Adrenal Insufficiency. Cureus. 2022 Aug;14(8):e27605.
- Eid MM. COVID-19 patient with symptomatic bradycardia. Vis J Emerg Med. 2021 Jan;22:100920.
- Frustaci A, Verardo R, Galea N, Lavalle C, Bagnato G, Scialla R, Chimenti C. Hypersensitivity Myocarditis after COVID-19 mRNA Vaccination. J Clin Med. 2022 Mar 16;11(6)
- Vishnu VK, Jamshed N, Amrithanand VT, Thandar S. BRASH Syndrome: A Case Report. J Emerg Med. 2021 Jun;60(6):818-822.
- Drumheller BC, Tuffy E, Gibney F, Stallard S, Siewers C, Korvek S. Severe bradycardia from severe hyperkalemia: Patient characteristics, outcomes and factors associated with hemodynamic support. Am J Emerg Med. 2022 May;55:117-125.
- Romhilt DW, Doyle M, Sagar KB, Hastillo A, Wolfgang TC, Lower RR, Hess ML. Prevalence and significance of arrhythmias in long-term survivors of cardiac transplantation. Circulation. 1982 Aug;66(2 Pt 2):I219-22.
- Angsubhakorn N, Anderson M, Akdemir B, Bertog S, Garcia S, Sharma A, Tholakanahalli V, Adabag S. Prevalence and Implications of Junctional Rhythm During Transcatheter Aortic Valve Replacement. Cardiovasc Revasc Med. 2021 May;26:61-62.
- Rodriguez RD, Schocken DD. Update on sick sinus syndrome, a cardiac disorder of aging. Geriatrics. 1990 Jan;45(1):26-30, 33-6.
- Sanders P, Kistler PM, Morton JB, Spence SJ, Kalman JM. Remodeling of sinus node function in patients with congestive heart failure: reduction in sinus node reserve. Circulation. 2004 Aug 24;110(8):897-903.
- Kim D, Shinohara T, Joung B, Maruyama M, Choi EK, On YK, Han S, Fishbein MC, Lin SF, Chen PS. Calcium dynamics and the mechanisms of atrioventricular junctional rhythm. J Am Coll Cardiol. 2010 Aug 31;56(10):805-12.
- Cools E, Missant C. Junctional ectopic tachycardia after congenital heart surgery. Acta Anaesthesiol Belg. 2014;65(1):1-8.
- Di Biase L, Gianni C, Bagliani G, Padeletti L. Arrhythmias Involving the Atrioventricular Junction. Card Electrophysiol Clin. 2017 Sep;9(3):435-452.
- Tuohy S, Saliba W, Pai M, Tchou P. Catheter ablation as a treatment of atrioventricular block. Heart Rhythm. 2018 Jan;15(1):90-96.
- Antman EM, Wenger TL, Butler VP, Haber E, Smith TW. Treatment of 150 cases of life-threatening digitalis intoxication with digoxin-specific Fab antibody fragments. Final report of a multicenter study. Circulation. 1990 Jun;81(6):1744-52
- Hauptman PJ, Kelly RA. Digitalis. Circulation. 1999 Mar 09;99(9):1265-70.
- Kelly RA, Smith TW. Recognition and management of digitalis toxicity. Am J Cardiol. 1992 Jun 04;69(18):108G-118G; disc. 118G-119G.
- Dobrzynski H, Boyett MR, Anderson RH. New insights into pacemaker activity: promoting understanding of sick sinus syndrome. Circulation. 2007 Apr 10;115(14):1921-32.
- Ashraf M, Collier SA. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): May 13, 2025. Junctional Ectopic Tachycardia.
- Misumi I, Yamakawa M, Harada M, Sato K, Tabira A, Usuku H, Tsujita K. Severe hypotension during junctional rhythm in a patient with multiple cerebral infarcts. J Cardiol Cases. 2023 Feb;27(2):84-87.
References
Spodick DH. Normal sinus heart rate: sinus tachycardia and sinus bradycardia redefined. Am Heart J. 1992 Oct;124(4):1119-21.
Thery C, Gosselin B, Lekieffre J, Warembourg H. Pathology of sinoatrial node. Correlations with electrocardiographic findings in 111 patients. Am Heart J. 1977 Jun;93(6):735-40.
Dobrzynski H, Anderson RH, Atkinson A, Borbas Z, D'Souza A, Fraser JF, Inada S, Logantha SJ, Monfredi O, Morris GM, Moorman AF, Nikolaidou T, Schneider H, Szuts V, Temple IP, Yanni J, Boyett MR. Structure, function and clinical relevance of the cardiac conduction system, including the atrioventricular ring and outflow tract tissues. Pharmacol Ther. 2013 Aug;139(2):260-88.
Van der Hauwaert LG, Stroobandt R, Verhaeghe L. Arterial blood supply of the atrioventricular node and main bundle. Br Heart J. 1972 Oct;34(10):1045-51.
Pejković B, Krajnc I, Anderhuber F, Kosutić D. Anatomical aspects of the arterial blood supply to the sinoatrial and atrioventricular nodes of the human heart. J Int Med Res. 2008 Jul-Aug;36(4):691-8.
Chua K, Upadhyay GA, Lee E, Aziz Z, Beaser AD, Ozcan C, Broman M, Nayak HM, Tung R. High-resolution mapping of the triangle of Koch: Spatial heterogeneity of fast pathway atrionodal connections. Heart Rhythm. 2018 Mar;15(3):421-429.
Semelka M, Gera J, Usman S. Sick sinus syndrome: a review. Am Fam Physician. 2013 May 15;87(10):691-6.
Trappe HJ. Tachyarrhythmias, bradyarrhythmias and acute coronary syndromes. J Emerg Trauma Shock. 2010 Apr;3(2):137-42.
Silvestri NJ, Ismail H, Zimetbaum P, Raynor EM. Cardiac involvement in the muscular dystrophies. Muscle Nerve. 2018 May;57(5):707-715.
Patel P, Kelschenbach K. Case of Junctional Rhythm in the Setting of Acute Adrenal Insufficiency. Cureus. 2022 Aug;14(8):e27605.
Eid MM. COVID-19 patient with symptomatic bradycardia. Vis J Emerg Med. 2021 Jan;22:100920.
Frustaci A, Verardo R, Galea N, Lavalle C, Bagnato G, Scialla R, Chimenti C. Hypersensitivity Myocarditis after COVID-19 mRNA Vaccination. J Clin Med. 2022 Mar 16;11(6)
Vishnu VK, Jamshed N, Amrithanand VT, Thandar S. BRASH Syndrome: A Case Report. J Emerg Med. 2021 Jun;60(6):818-822.
Drumheller BC, Tuffy E, Gibney F, Stallard S, Siewers C, Korvek S. Severe bradycardia from severe hyperkalemia: Patient characteristics, outcomes and factors associated with hemodynamic support. Am J Emerg Med. 2022 May;55:117-125.
Romhilt DW, Doyle M, Sagar KB, Hastillo A, Wolfgang TC, Lower RR, Hess ML. Prevalence and significance of arrhythmias in long-term survivors of cardiac transplantation. Circulation. 1982 Aug;66(2 Pt 2):I219-22.
Angsubhakorn N, Anderson M, Akdemir B, Bertog S, Garcia S, Sharma A, Tholakanahalli V, Adabag S. Prevalence and Implications of Junctional Rhythm During Transcatheter Aortic Valve Replacement. Cardiovasc Revasc Med. 2021 May;26:61-62.
Rodriguez RD, Schocken DD. Update on sick sinus syndrome, a cardiac disorder of aging. Geriatrics. 1990 Jan;45(1):26-30, 33-6.
Sanders P, Kistler PM, Morton JB, Spence SJ, Kalman JM. Remodeling of sinus node function in patients with congestive heart failure: reduction in sinus node reserve. Circulation. 2004 Aug 24;110(8):897-903.
Kim D, Shinohara T, Joung B, Maruyama M, Choi EK, On YK, Han S, Fishbein MC, Lin SF, Chen PS. Calcium dynamics and the mechanisms of atrioventricular junctional rhythm. J Am Coll Cardiol. 2010 Aug 31;56(10):805-12.
Cools E, Missant C. Junctional ectopic tachycardia after congenital heart surgery. Acta Anaesthesiol Belg. 2014;65(1):1-8.
Di Biase L, Gianni C, Bagliani G, Padeletti L. Arrhythmias Involving the Atrioventricular Junction. Card Electrophysiol Clin. 2017 Sep;9(3):435-452.
Tuohy S, Saliba W, Pai M, Tchou P. Catheter ablation as a treatment of atrioventricular block. Heart Rhythm. 2018 Jan;15(1):90-96.
Antman EM, Wenger TL, Butler VP, Haber E, Smith TW. Treatment of 150 cases of life-threatening digitalis intoxication with digoxin-specific Fab antibody fragments. Final report of a multicenter study. Circulation. 1990 Jun;81(6):1744-52
Hauptman PJ, Kelly RA. Digitalis. Circulation. 1999 Mar 09;99(9):1265-70.
Kelly RA, Smith TW. Recognition and management of digitalis toxicity. Am J Cardiol. 1992 Jun 04;69(18):108G-118G; disc. 118G-119G.
Dobrzynski H, Boyett MR, Anderson RH. New insights into pacemaker activity: promoting understanding of sick sinus syndrome. Circulation. 2007 Apr 10;115(14):1921-32.
Ashraf M, Collier SA. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): May 13, 2025. Junctional Ectopic Tachycardia.
Misumi I, Yamakawa M, Harada M, Sato K, Tabira A, Usuku H, Tsujita K. Severe hypotension during junctional rhythm in a patient with multiple cerebral infarcts. J Cardiol Cases. 2023 Feb;27(2):84-87.