Pearls of Knowledge: Junctional Rhythms

Dysrhythmias: Junctional rhythms 

Pearls of Knowledge          ©    

In junctional rhythm, the SA node is no longer in control and the AV node becomes the pacemaker by default due to the property of automaticity. Because the AV node is a less reliable pacemaker, the development of junctional rhythm is cause for concern. The analysis of junctional rhythms is determined by the P waves and the rate. 

Because the impulse starts in the AV node, the atria are depolarized in a retrograde manner resulting in an inverted P wave in the upright (positive) leads (such as lead II).

Analysis of inverted P waves (in the upright leads) 

  • Inverted P wave before the QRS when the atria depolarize before the ventricles. 
  • Inverted P wave buried in the QRS when the atria and ventricles depolarize at the same time. 
  • Inverted P wave after the QRS when the ventricles depolarize before the atria. 


Analysis of rate 

  • Junctional rhythm: HR 40-60 BPM. 
  • Accelerated junctional rhythm: HR 60-100 BPM. 
  • Junctional tachycardia: HR greater than 100 BPM.


Rhythm strips 

Junctional rhythm. HR=52 BPM. QRS=0.08. 

Accelerated junctional rhythm. HR=58 BPM. QRS=0.08.

Junctional tachycardia. HR=115 BPM. QRS=0.08.


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