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Diagnosis and Treatment |

The "R-on-T" Phenomenon: An Update and Critical Review

TOBY R. ENGEL, M.D., F.A.C.P.; STEVEN G. MEISTER, M.D., F.A.C.P.; and WILLIAM S. FRANKL, M.D., F.A.C.P.
[+] Article and Author Information

Grant support: in part by a grant from the American Heart Association, Southeastern Pennsylvania Chapter.

Dr. Engel is a Career Development Investigator of the Southeastern Pennsylvania Heart Association.

▸Requests for reprints should be addressed to Toby R. Engel, M.D.; Cardiovascular Division, The Medical College of Pennsylvania, 3300 Henry Ave.; Philadelphia, PA 19129.


Philadelphia, Pennsylvania


Ann Intern Med. 1978;88(2):221-225. doi:10.7326/0003-4819-88-2-221
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The "R-on-T phenomenon" is the superimposition of an ectopic beat on the T wave of a preceding beat. Early observations suggested that R-on-T was likely to initiate sustained ventricular tachyarrhythmias. More recent experimental and clinical observations suggest that R-on-T is not a critical determinant of primary ventricular fibrillation in acute myocardial infarction; represents few of the initiating beats of paroxysmal ventricular tachycardia; and represents at worst only a small risk in terms of sudden death. Apparently when the capacity for sustained repetitive beating has not been clinically obvious, R-on-T is quite unlikely to result in ventricular tachyarrhythmias, even in the presence of coronary heart disease. However, in the setting of acute myocardial infarction, inability to always identify the precursors of tachyarrhythmias strengthens the argument for prophylactic treatment of patients.

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