Case Presentation – ECG Library

Case Presentation:

A 60-year-old male presents to the emergency department with complaints of dizziness and palpitations over the past two days. He reports no chest pain, shortness of breath, or syncope. His medical history includes hypertension and type 2 diabetes mellitus. He is on antihypertensive medication and metformin.

Physical Examination

On examination, the patient is alert and oriented. Vital signs show a heart rate of 45 beats per minute, blood pressure of 130/80 mmHg, respiratory rate of 18 breaths per minute, and oxygen saturation of 98% on room air. Cardiac auscultation reveals a regular rhythm with no murmurs.

Initial Investigations

An ECG is performed, revealing a heart rate of 49 bpm with narrow QRS complexes and absent P waves preceding each QRS complex. Based on these findings, a diagnosis of junctional rhythm is considered.

Junctional Rhythm ECG

Identifying the Cause

Further evaluation revealed that the patient had been taking an increased dose of beta-blockers to manage his hypertension. This medication adjustment likely contributed to the development of the junctional rhythm.

What is Junctional Rhythm?

Junctional rhythm is an arrhythmia originating from the atrioventricular (AV) junction. It occurs when the sinoatrial (SA) node fails to initiate an impulse, and the AV node takes over as the pacemaker of the heart. This rhythm typically has a rate between 40 to 60 beats per minute.

Causes of Junctional Rhythm

Several conditions can lead to the development of a junctional rhythm, including:

  • SA node dysfunction: Due to sick sinus syndrome or ischemia.
  • Increased vagal tone: Often seen in athletes or during sleep.
  • Medications: Digoxin toxicity, beta-blockers, calcium channel blockers.
  • Myocardial infarction: Particularly involving the inferior wall.
  • Electrolyte imbalances: Such as hyperkalemia or hypokalemia.
  • Cardiac surgery: Especially after valve surgery or congenital heart defect repairs.

ECG Findings in Junctional Rhythm

The ECG characteristics of a junctional rhythm include:

  • Rate: Typically 40-60 bpm, although it can be faster in accelerated junctional rhythm.
  • Rhythm: Regular.
  • P waves: Absent, inverted, or retrograde (after the QRS complex).
  • PR interval: If P waves are present, the PR interval is usually short.
  • QRS complex: Normal (narrow).

Signs and Symptoms

Patients with junctional rhythm may experience a variety of symptoms, including:

  • Dizziness or lightheadedness
  • Palpitations
  • Fatigue
  • Exercise intolerance
  • Syncope (in severe cases)

However, some patients may remain asymptomatic, especially if the heart rate is adequate to maintain cardiac output.

Diagnosis of Junctional Rhythm

Clinical Evaluation

The diagnosis of junctional rhythm primarily relies on clinical history and physical examination. A thorough assessment of symptoms and medical history is essential.


The definitive diagnosis is made using an ECG, which demonstrates the characteristic features of a junctional rhythm.

Additional Tests

  • Laboratory tests: To identify potential underlying causes, such as electrolyte imbalances or drug levels.
  • Echocardiogram: To assess structural heart disease.
  • Holter monitor: To evaluate the frequency and duration of junctional episodes.

Treatment of Junctional Rhythm

Addressing the Underlying Cause

  • Medication adjustments: Stopping or adjusting doses of drugs that may contribute to the rhythm.
  • Electrolyte correction: Managing imbalances such as hyperkalemia or hypokalemia.
  • Treating ischemia: In cases of myocardial infarction.

Symptomatic Management

  • Atropine: For bradycardia causing significant symptoms.
  • Temporary pacing: In cases of hemodynamic instability or severe bradycardia.
  • Permanent pacemaker: Considered if junctional rhythm is persistent and symptomatic, particularly in the context of sick sinus syndrome.


While junctional rhythm itself is often benign, it can lead to several complications if left untreated, including:

  • Severe bradycardia: Leading to decreased cardiac output and syncope.
  • Heart failure: Due to inadequate heart rate.
  • Pacemaker dependence: If a permanent pacemaker is required.


Junctional rhythm is an arrhythmia originating from the AV junction, often presenting with bradycardia and potentially symptomatic. Diagnosis is primarily ECG-based, with management focusing on treating the underlying cause and symptomatic relief. Awareness and prompt treatment are essential to prevent complications and ensure optimal patient outcomes.

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