Supraventricular escape rhythms during transient episodes of bradycardia in preterm infants

OBJECTIVE: To evaluate the origin of transient episodes of sinus bradycardia, atrial escape rhythm, and atrioventricular nodal escape rhythm in preterm infants. MATERIAL AND METHODS: The study was observational, and was carried out in a third level neonatal intensive care unit. We studied 19 spontaneously breathing infants born healthy but prior to term, the examinations being carried out between the ages of 3 and 28 days. The mean gestational age was 29.2 +/- 1.9 weeks, and the mean birth weight was 1154 +/- 264 g. Transient episodes of bradycardia were defined as a decline in heart rate equal to or greater than 25% from baseline, lasting for at least 3 successive RR-intervals. To discriminate between different types of escape mechanisms, we used the P wave and the P axis of the electrocardiogram. Sinus bradycardia was diagnosed when the P axis was from +0 to +90 degrees; atrial escape rhythm when it was from +91 to +359 degrees, and atrioventricular nodal escape rhythm when the P wave was absent, hidden, or followed the QRS complex. RESULTS: The mean P axis was +50 +/- 11 degrees. We observed 60 transient episodes of bradycardia in 11 of the 19 infants. Of these, 34 (57%) were classified as sinus bradycardia, and 13 (22%) as atrial escapes. Atrioventricular nodal escapes developed during 6 episodes (10%), while 7 episodes (11%) could not be classified. CONCLUSIONS: Atrial excitation as evidenced by the P axis during sinus rhythm is similar in very preterm infants to that seen in children and adults. Escape rhythms with different origins occur during transient episodes of bradycardia in healthy preterm infants. In at least one third, the episodes are due to atrial or atrioventricular nodal escape.