Atrioventricular Nodal Reentry Tachycardia (AVNRT)


Article Author:
Yamama Hafeez


Article Editor:
Tyler Armstrong


Editors In Chief:
William Gossman


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Pritesh Sheth
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes
Kavin Sugumar


Updated:
5/14/2019 3:49:52 PM

Introduction

The atrioventricular (AV) node is a subendocardial structure located in the inferior-posterior right atrium. In an average adult, an AV node measures approximately 1 x 3 x 5 millimeters and sits within an anatomic region bordered posteriorly by the coronary sinus ostium, superiorly by the tendon of Todaro, and anteriorly by the septal tricuspid valve annulus. This anatomic region is also commonly referred to as the triangle of Koch. The blood supply to the AV node is from the AV nodal branch of the right coronary artery (90%) or the left circumflex artery (10%) depending on the right or left dominant blood supply to the heart. The first septal perforator of the left anterior descending artery also supplies blood to the AV node. [1][2][3][4][5][6][7]

Atrioventricular nodal reentrant tachycardia (AVNRT) is a type of paroxysmal supraventricular tachycardia that results due to the presence of a re-entry circuit within or adjacent to the AV node. Diagnosis of AVNRT requires visualization of an electrocardiogram (ECG). In most cases, an ECG will show heart rate between 140 and 280 beats per minute (bpm), and in the absence of aberrant conduction, a QRS complex of fewer than 120 milliseconds. [8][9][10]ECG criteria based on the re-entrant circuits are as follows:

Slow-Fast AVNRT

  • Pseudo-S wave in Leads II, III, and AVF
  • Pseudo-R' in lead V1.

Fast-Slow AVNRT

  • P waves between the QRS and T waves (QRS-P-T complexes)

Slow-Slow AVNRT

  • Late P waves after a QRS. Often appears as atrial tachycardia.

Etiology

Atrioventricular nodal reentry tachycardia is usually not prevalent in patients with structural heart disease. The anatomy of the re-entrant circuit defines the type of AVNRT present. A Slow-Fast AVNRT accounts for 90% of AVNRTs with anterograde conduction by the slow AV nodal pathway and retrograde conduction by the fast AV nodal pathway. Fast-slow AVNRT represents approximately 5% to 10% of AVNRTs with anterograde conduction by the fast AV nodal pathway and retrograde conduction by the slow AV nodal pathway. Slow-slow AVNRTs account for 1% to 5% of AVNRTs with anterograde conduction by slow AV nodal pathways and retrograde conduction by slow atrial fibers.[10][11]

Epidemiology

Prevalence of atrioventricular nodal reentry tachycardia globally is similar to the United States. Close to 60% of the paroxysmal supraventricular tachycardia is AVNRT, with approximately two-thirds of that in women. A study found that the majority of patients presenting with symptoms due to AVNRT are in their twenties, but some patients might present with AVNRT in their seventh or eighth decade.[12]

Pathophysiology

A reentry circuit requires a difference in conduction velocity and refractory period. A fast conduction pathway has rapid conduction but a slow refractory period, whereas a slow conduction pathway has a rapid refractory period coupled with slow conduction.[10][13]

Histopathology

Despite being examined, it remains controversial whether fast and slow AV nodal conduction pathways share anatomical distinction or whether they represent functional diversity in the nodal structure.[14]

History and Physical

Patients with atrioventricular nodal reentrant tachycardia usually present with symptoms of dizziness, syncope, shortness of breath, intermittent palpitations, pain/discomfort in the neck, pain/discomfort in the chest, anxiety, and polyuria secondary atrial natriuretic factor secreted mainly by the heart atria in response to atrial stretch. Patients with AVNRT and known history of coronary artery disease may present with a myocardial infarction secondary to the stress on the heart. Patients with AVNRT and known history of heart failure may present with acute exacerbation and possibly reduced ejection fraction secondary to tachycardia-induced cardiomyopathy.[15]

Although syncope is an uncommon symptom in patients with AVNRT, it is typical in patients who have a heart rate above 170 bpm as less filling of the ventricles leads to the reduction in cardiac output and the decreased perfusion of the brain. Depression of the sinoatrial node secondary to tachycardia also may contribute to syncopal symptoms of patients who present with AVNRT. [16]

Patients with AVNRT usually present with a heart rate within the range of 140 to 280 bpm. If a patient has known heart failure or coronary artery disease, he may complain of chest pain and also may have symptoms of heart failure such as tachypnea with wheezes or swelling in the lower extremities on physical exam. During a physical exam, a provider might be able to appreciate Cannon A waves as the atrium contracts in conjunction with the ventricular contractions against a closed tricuspid valve. Hypotension secondary to decreased ventricular filling also may be a significant physical exam finding in patients presenting with AVNRT.[17]

Evaluation

The most significant component of the assessment for a patient who presents with signs and symptoms of atrioventricular nodal reentrant tachycardia is a history and physical exam. These should include vital signs (respiratory rate, blood pressure, temperature, and heart rate) and an electrocardiogram. A patient presenting with AVNRT should undergo evaluation for any unknown underlying coronary artery disease or heart failure. During an assessment, it should be established whether the patient is hemodynamically stable based mainly on his blood pressure, mental status, and respiratory rate. Initial evaluation of patients with AVNRT can include testing to access the patient's thyroid and pulmonary function, together with routine blood work and echocardiography.[18][19]

Treatment / Management

Management of patients presenting with atrioventricular nodal reentry tachycardia begins with an initial evaluation of their hemodynamically stability. Hemodynamically unstable patients present with tachycardia associated with hypotension, ischemic chest pain, altered mental status, respiratory failure, or shock. These patients need their AVNRT terminated electrically with an urgent electrical cardioversion. Hemodynamically stable patients should be treated first with vagal maneuvers to cease the rhythm acutely. If attempted twice and the patient remains in AVNRT, modified vagal exercises should be performed at least twice to terminate the arrhythmia. Once such maneuvers are unsuccessful or are inappropriate, intravenous (IV) medical therapy is warranted.[20][21][22]

First-line medical therapy is IV adenosine which can be administered up to 18 mg given in increments of 6 mg in the absence of contraindications such as severe bronchospastic lung disease or severe coronary artery disease. In the event both vagal maneuvers and IV adenosine are unsuccessful or ruled inappropriate,  IV non-dihydropyridine calcium channel blockers, IV beta-blockers or IV digoxin are next in consideration. Selection of these IV medical agents is based upon the presence of concomitant factors, such as in patients with AVNRT and hypotension; IV digoxin may be appropriate as it lacks anti-hypertensive properties. Subsequently, in a patient who is actively wheezing secondary to a reactive airway, IV non-dihydropyridine calcium channel blockers should be used first.[23][24][25][26][27][28][29][30]

IV adenosine terminates approximately 80% of AVNRT arrhythmias. Patients in whom medical treatment and Valsalva maneuvers fail or those who cannot tolerate medication due to its side effects might opt for catheter ablation as a one-time definitive cure. Catheter ablations in patients with AVNRT have a high success rate which is reported to be as high as 95%. Chronic medical therapy with Class III or IC antiarrhythmics such as flecainide, propafenone, amiodarone, dofetilide or sotalol can be done in instances where the patient does not respond to calcium channel blockers or beta-blockers and refuses catheter ablation. Selection of these antiarrhythmics usually is based on patients comorbidities and its side effect profiles.[31][32][33]

Differential Diagnosis

Once a narrow QRS complex tachycardia is present on an electrocardiogram, and the rhythm is evaluated as regular, differential rhythms include the following[34]:

  • Atrioventricular nodal reentrant tachycardia
  • Atrioventricular reentrant tachycardia
  • Intraatrial reentrant tachycardia
  • Sinoatrial nodal reentrant tachycardia
  • Junctional ectopic tachycardia
  • Atrial tachycardia
  • Atrial flutter
  • Sinus tachycardia
  • Inappropriate sinus tachycardia

Prognosis

Prognosis is generally good when the rhythm is promptly identified by a healthcare provider. 

Complications

If not identified promptly symptomatic complications such as syncope, fatigue or dizziness can occur. 

Deterrence and Patient Education

Educating patients at risk for this rhythm and making a closed loop communication between them and their providers can help further improve the management of these rhythms.

Pearls and Other Issues

In rare instances, atrioventricular nodal reentry tachycardia can result in sudden cardiac arrest.[35]

Enhancing Healthcare Team Outcomes

If available patient education should be provided using resources familiar to the patient including online resources and pamphlets. 


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Atrioventricular Nodal Reentry Tachycardia (AVNRT) - Questions

Take a quiz of the questions on this article.

Take Quiz
Atrioventricular nodal reentry tachycardia is most commonly seen in which condition?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
In an atrioventricular nodal reentry tachycardia, antegrade conduction flows in which direction?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 27-year-old African American female with past medical history of type 2 diabetes mellitus and hyperlipidemia presents to her primary care provider's clinic with symptoms of dizziness and palpitations. On physical examination, she has pounding neck veins with a regular heart rate of 210 bpm; blood pressure is 120/76 mmHg, respiratory rate of 18/minute, and temperature of 97.8 F. What is the next step in the management of this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 63-year-old African American female with past medical history of coronary artery disease, hypertension, type 2 diabetes mellitus, and hyperlipidemia presents with symptoms of dizziness, palpitations and chest pain. On physical examination, she has pounding neck veins with a regular heart rate of 180 bpm; blood pressure is 80/40 mmHg, respiratory rate of 19/minute, and temperature of 98.4 F. Her electrocardiogram shows a regular narrow QRS complex rhythm with a pseudo-S wave in Leads II, III, AVF and pseudo-R' in lead V1. What is the next step in the management of this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 20-year-old African American female with past medical history of depression presents to her primary care provider's clinic with symptoms of palpitations. On physical examination, she has pounding neck veins with a regular heart rate of 193 bpm; blood pressure is 126/83, respiratory rate of 18, and temperature of 97.4 F. Her electrocardiogram shows a regular narrow QRS complex rhythm with a pseudo-S wave in leads II, III, AVF and pseudo-R' in lead V1. What is the next step in the management of this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old white female with past medical history of bipolar disorder presents to her primary care provider's clinic with symptoms of palpitations and dizziness. On physical examination, she has pounding neck veins with a regular heart rate of 213 bpm; blood pressure is 131/73 mmHg, respiratory rate of 19/minute, and temperature of 98.1 F. Her electrocardiogram shows a regular narrow QRS complex rhythm with P waves between the QRS and T waves (QRS-P-T complexes). The patient attempts Valsalva maneuvers twice but fails to terminate the tachyarrhythmia. What is the next step in the management of this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 31-year-old white female with past medical history of type 2-diabetes and asthma presents with symptoms of wheezing, palpitations, and dizziness. On physical examination, she has pounding neck veins with a regular heart rate of 221 bpm; blood pressure is 137/75 mmHg, respiratory rate of 18/minute, and temperature of 98.0 F. Her electrocardiogram shows a regular narrow QRS complex rhythm with P waves between the QRS and T waves (QRS-P-T complexes). The patient attempts Valsalva maneuvers and modified Valsalva maneuvers but fails to terminate the tachyarrhythmia. What is the next step in the management of this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Atrioventricular Nodal Reentry Tachycardia (AVNRT) - References

References

Determinants of immediate success for catheter ablation of atrioventricular nodal reentry tachycardia in patients without junctional rhythm., Bagherzadeh A,Keshavarzi T,Farahani MM,Goodarzynejad H,, Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing, 2014 Jan     [PubMed]
A simple model of the right atrium of the human heart with the sinoatrial and atrioventricular nodes included., Podziemski P,Zebrowski JJ,, Journal of clinical monitoring and computing, 2013 Aug     [PubMed]
Anatomical and electrophysiological variations of Koch's triangle and the impact on the slow pathway ablation in patients with atrioventricular nodal reentrant tachycardia: a study using 3D mapping., Yamaguchi T,Tsuchiya T,Nagamoto Y,Miyamoto K,Sadamatsu K,Tanioka Y,Kadokami T,Murotani K,Takahashi N,, Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing, 2013 Jun     [PubMed]
Atrioventricular Reentrant Tachycardia., Marzlin KM,Webner C,, AACN advanced critical care, 2017 Summer     [PubMed]
Atrioventricular Nodal Reentrant Tachycardia., Marzlin KM,, AACN advanced critical care, 2017 Spring     [PubMed]
Koch's triangle sized up: anatomical landmarks in perspective of catheter ablation procedures., Inoue S,Becker AE,, Pacing and clinical electrophysiology : PACE, 1998 Aug     [PubMed]
Clinical importance of Koch's triangle size in children: a study using 3-dimensional electroanatomical mapping., Sumitomo N,Tateno S,Nakamura Y,Ushinohama H,Taniguchi K,Ichikawa R,Fukuhara J,Abe O,Miyashita M,Kanamaru H,Ayusawa M,Harada K,Mugishima H,, Circulation journal : official journal of the Japanese Circulation Society, 2007 Dec     [PubMed]
Koch's triangle and the atrioventricular node in Ebstein's anomaly: implications for catheter ablation., Sánchez-Quintana D,Picazo-Angelín B,Cabrera A,Murillo M,Cabrera JA,, Revista espanola de cardiologia, 2010 Jun     [PubMed]
Arterial blood supply of the atrioventricular node and main bundle., Van der Hauwaert LG,Stroobandt R,Verhaeghe L,, British heart journal, 1972 Oct     [PubMed]
Anatomical aspects of the arterial blood supply to the sinoatrial and atrioventricular nodes of the human heart., Pejković B,Krajnc I,Anderhuber F,Kosutić D,, The Journal of international medical research, 2008 Jul-Aug     [PubMed]
Arterial supply to sinuatrial and atrioventricular nodes: imaging with multidetector CT., Saremi F,Abolhoda A,Ashikyan O,Milliken JC,Narula J,Gurudevan SV,Kaushal K,Raney A,, Radiology, 2008 Jan     [PubMed]
Arrhythmias Involving the Atrioventricular Junction., Di Biase L,Gianni C,Bagliani G,Padeletti L,, Cardiac electrophysiology clinics, 2017 Sep     [PubMed]
Gender-related differences in patients with atrioventricular nodal reentry tachycardia., Liuba I,Jönsson A,Säfström K,Walfridsson H,, The American journal of cardiology, 2006 Feb 1     [PubMed]
Contemporary management of paroxysmal supraventricular tachycardia., Ferguson JD,DiMarco JP,, Circulation, 2003 Mar 4     [PubMed]
Supraventricular tachycardia., Ganz LI,Friedman PL,, The New England journal of medicine, 1995 Jan 19     [PubMed]
Comparison of the ages of tachycardia onset in patients with atrioventricular nodal reentrant tachycardia and accessory pathway-mediated tachycardia., Goyal R,Zivin A,Souza J,Shaikh SA,Harvey M,Bogun F,Daoud E,Man KC,Strickberger SA,Morady F,, American heart journal, 1996 Oct     [PubMed]
Physiologic evidence for a dual A-V transmission system., MOE GK,PRESTON JB,BURLINGTON H,, Circulation research, 1956 Jul     [PubMed]
Neurohumoral and hemodynamic mechanisms of diuresis during atrioventricular nodal reentrant tachycardia., Abe H,Nagatomo T,Kobayashi H,Miura Y,Araki M,Kuroiwa A,Nakashima Y,, Pacing and clinical electrophysiology : PACE, 1997 Nov     [PubMed]
Frequency of disabling symptoms in supraventricular tachycardia., Wood KA,Drew BJ,Scheinman MM,, The American journal of cardiology, 1997 Jan 15     [PubMed]
Studies on hemodynamic instability in paroxysmal supraventricular tachycardia: noninvasive evaluations by head-up tilt testing and power spectrum analysis on electrocardiographic RR variation., Doi A,Miyamoto K,Uno K,Nakata T,Tsuchihashi K,Shimamoto K,, Pacing and clinical electrophysiology : PACE, 2000 Nov     [PubMed]
Syncope associated with supraventricular tachycardia. An expression of tachycardia rate or vasomotor response?, Leitch JW,Klein GJ,Yee R,Leather RA,Kim YH,, Circulation, 1992 Mar     [PubMed]
Patients with supraventricular tachycardia presenting with aborted sudden death: incidence, mechanism and long-term follow-up., Wang YS,Scheinman MM,Chien WW,Cohen TJ,Lesh MD,Griffin JC,, Journal of the American College of Cardiology, 1991 Dec     [PubMed]
2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society., Page RL,Joglar JA,Caldwell MA,Calkins H,Conti JB,Deal BJ,Estes NA 3rd,Field ME,Goldberger ZD,Hammill SC,Indik JH,Lindsay BD,Olshansky B,Russo AM,Shen WK,Tracy CM,Al-Khatib SM,, Circulation, 2016 Apr 5     [PubMed]
Valsalva maneuver for termination of supraventricular tachycardia., Pandya A,Lang E,, Annals of emergency medicine, 2015 Jan     [PubMed]
Electrophysiologic effects of adenosine in patients with supraventricular tachycardia., Glatter KA,Cheng J,Dorostkar P,Modin G,Talwar S,Al-Nimri M,Lee RJ,Saxon LA,Lesh MD,Scheinman MM,, Circulation, 1999 Mar 2     [PubMed]
Intravenous adenosine in the emergency department management of paroxysmal supraventricular tachycardia., Cairns CB,Niemann JT,, Annals of emergency medicine, 1991 Jul     [PubMed]
Adenosine and the treatment of supraventricular tachycardia., Rankin AC,Brooks R,Ruskin JN,McGovern BA,, The American journal of medicine, 1992 Jun     [PubMed]
Intravenous verapamil for termination of re-entrant supraventricular tachycardias: intracardiac studies correlated with plasma verapamil concentrations., Sung RJ,Elser B,McAllister RG Jr,, Annals of internal medicine, 1980 Nov     [PubMed]
Adenosine: electrophysiologic effects and therapeutic use for terminating paroxysmal supraventricular tachycardia., DiMarco JP,Sellers TD,Berne RM,West GA,Belardinelli L,, Circulation, 1983 Dec     [PubMed]
Acute conversion of paroxysmal supraventricular tachycardia with intravenous diltiazem. IV Diltiazem Study Group., Dougherty AH,Jackman WM,Naccarelli GV,Friday KJ,Dias VC,, The American journal of cardiology, 1992 Sep 1     [PubMed]
Episodic drug treatment in the management of paroxysmal arrhythmias., Margolis B,DeSilva RA,Lown B,, The American journal of cardiology, 1980 Mar     [PubMed]
Efficacy and safety of out-of-hospital self-administered single-dose oral drug treatment in the management of infrequent, well-tolerated paroxysmal supraventricular tachycardia., Alboni P,Tomasi C,Menozzi C,Bottoni N,Paparella N,Fucà G,Brignole M,Cappato R,, Journal of the American College of Cardiology, 2001 Feb     [PubMed]
Meta-analysis of ablation of atrial flutter and supraventricular tachycardia., Spector P,Reynolds MR,Calkins H,Sondhi M,Xu Y,Martin A,Williams CJ,Sledge I,, The American journal of cardiology, 2009 Sep 1     [PubMed]
Current management and clinical outcomes for catheter ablation of atrioventricular nodal re-entrant tachycardia., Chrispin J,Misra S,Marine JE,Rickard J,Barth A,Kolandaivelu A,Ashikaga H,Tandri H,Spragg DD,Crosson J,Berger RD,Tomaselli G,Calkins H,Sinha SK,, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology, 2018 Apr 1     [PubMed]
Catheter Ablation of Atypical Atrioventricular Nodal Reentrant Tachycardia., Katritsis DG,Marine JE,Contreras FM,Fujii A,Latchamsetty R,Siontis KC,Katritsis GD,Zografos T,John RM,Epstein LM,Michaud GF,Anter E,Sepahpour A,Rowland E,Buxton AE,Calkins H,Morady F,Stevenson WG,Josephson ME,, Circulation, 2016 Nov 22     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Adult Ambulatory-Medical Student. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Adult Ambulatory-Medical Student, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Adult Ambulatory-Medical Student, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Adult Ambulatory-Medical Student. When it is time for the Adult Ambulatory-Medical Student board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Adult Ambulatory-Medical Student.