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Anterior Wall M.I. With Ventricular Bigeminy

Submitted by Dawn on Sat, 07/21/2018 - 17:29

The Patient     This ECG was obtained from a 51-year-old man who presented to EMS with acute chest pain. He had a history of hypertension, 40 pack-year smoker.

Hospital Course     He was diagnosed with anterior wall STEMI and taken to the cath lab.  He was rated Killips Class 1 (no evidence of congestive heart failure), TIMI risk score 4  (14% risk of all-cause 30-day mortality).  He underwent primary percutaneous coronary intervention (PCI) of the proximal left anterior descending coronary artery (LAD).

Ten days post PCI, the patient had ventricular arrhythmias and went into cardiac arrest, but was resuscitated. He continued to have occurrences of non-sustained ventricular tachycardia (VT), progressing to sustained VT.  Electrolytes were monitored and corrected when necessary. The patient expired before any further diagnosis was made.

ECG Interpretation    The rhythm is sinus at a rate of about 80 bpm (first two beats).  The PR interval is about .18 seconds.  The QRS duration is about .10 seconds.  After the second sinus beat, ventricular bigeminy occurs. Every other sinus beat is obscured by the PVCs.  By the end of the strip, the underlying sinus rhythm has slowed slightly.

The ECG signs that the ectopic beats are ventricular are:  lack of P waves associated with the premature beats, QRS width about .16 seconds, and compensatory pauses.  The axis of the sinus beats is around 60 degrees (normal), but the axis of the premature beats is difficult to determine due to the low voltage and biphasic QRS complexes in the frontal plane leads.  It is also difficult to determine ST and T wave changes in the PVCs for the same reason.

Dawn's picture

ECG Basics: Sinus Rhythm With Ventricular Bigeminy

Submitted by Dawn on Tue, 07/07/2015 - 15:03

This rhythm strip offers two leads taken at the same time, Lead II and Lead V1.  The Lead II strip may not look "typical" to a beginning student, because the sinus beats are very small and biphasic.  This is due to an axis shift, which cannot be evaluated without more leads.

One of the best teaching opportunities in this strip is the concept of "underlying rhythm" with ectopy.  The underlying rhythm here is sinus.  But there are sinus P waves which are hidden, making the sinus rate twice what it appears to be.  The P waves are invisible in the Lead II strip, with baseline artifact making them even harder to see.  But in V1, we are able to find them at the end of the PVCs' T waves.  The sinus rhythm is a bit irregular toward the end of the strip.  There are probably many things a more advanced practitioner could say about this strip, but it usually requires more than one or two leads to do a complete evaluation.  For your basic student, it is a good example of sinus rhythm with ventricular bigeminy.

Dawn's picture

ECG BASICS: Sinus Rhythm With Ventricular Bigeminy

Submitted by Dawn on Thu, 05/09/2013 - 13:20

Nice, clear example of ventricular bigeminy with an underlying sinus rhythm.  We do not know from this strip if the sinus rhythm is a bradycardia at a rate of about 42 per minute, or if the underlying sinus rhythm is actually at a rate of 85 per minute, with every other sinus beat inhibited by the occurance of a PVC.  In the first possibility, the ventricular beats would be considered "escape" beats, positively contributing to the patient's heart rate.  In the second instance, the rather late-occurring PVCs would cause the heart to be refractory, preventing the sinus P wave from conducting it's impulse to the ventricles.   Sometimes, we can see signs of the sinus P wave "hiding" in the PVC, but in this case, if P waves exist, they fall almost exactly in the middle of the ventricular beats' QRS complex, making them invisible.  A good strategy would be to watch the strip continuously for some time, hoping to catch the conduction of two sinus beats in a row, solving the dilemma.

Dawn's picture

Sinus Rhythm With Ventricular Bigeminy

Submitted by Dawn on Wed, 09/19/2012 - 15:17

This is a nice example of sinus rhythm with ventricular bigeminy in a patient with intermittent chest pain and hypertension.  The underlying rhythm is most likely normal sinus rhythm, but every other sinus P wave is most likely hidden in the PVCs, and not conducted due to the refractory state of the ventricles after the PVCs.  Often, signs of the "hidden" P waves will show in some leads, but that is difficult to demonstrate here.

It may be difficult to be sure of an adequate underlying rate, so the PVCs should not be eliminated with antiarrhythmic drugs until there is some ECG sign of a normal underlying rate.

Remember, the fourth channel on this ECG is a Lead II rhythm strip.  So, if you teach rate and rhythm monitoring, and don't want to use a 12-Lead ECG for your students, simply crop the bottom strip for your class.

Dawn's picture

How Do You Explain the Genesis and Significance of Ventricular Bigeminy to Your Students?

Submitted by Dawn on Sun, 03/18/2012 - 11:25

Our expert today is Darlene Hutton. She has worked in CCU, ICU, PACU, and Emergency as a bedside nurse, educator, and manager. She is currently working as a Clinical Research Manager at Rouge Valley Metabolic Research Associates in Toronto. Darlene also is an Educational Consultant providing workshops, seminars, and conferences on such topics as ECG Interpretation, Dysrhythmia Interpretation, Acute Coronary Syndromes and Cardiology Drugs. She is also an ACLS Course Director and runs courses throughout the province. Her company, QRS Educational Services, founded 18 years ago, provides education to nurses and other health care professionals throughout Canada. She is also the Department Head for Emergency Preparedness in the O.R. in the American College of Plastic Surgical Nursing journal.

Answer:

I PERSONALLY WENT THROUGH THIS 8 YEARS AGO...FUN TIMES. WHEN I WENT TO MY FAMILY DOCTOR HE STATED THE POTENTIAL CAUSES, IN THIS ORDER WERE: ADRENAL TUMOR, CARDIAC DISEASE. THOSE WERE HIS ONLY 2 OPTIONS. NEEDLESS TO SAY, I AM NO LONGER WITH THIS PRACTITIONER. THE 24 HR URINE WAS NEGATIVE AND THE CARDIAC STRESS TEST DID NOT INDUCE THE BIGEMINY, SO THAT WAS ALSO NEGATIVE. IN MY CASE, THE CAUSE CAN BE ATTRIBUTED TO THOSE WONDERFUL HORMONES THAT ACT UP IN THE PERIMENOPAUSAL PERIOD OF OUR LIVES.  I TEACH STUDENTS THAT THE HEART DOESN'T NORMALLY THROW OFF BIGEMINY, OR MULTIFOCAL PVCS, OR COUPLETS. WHEN IT DOES, WE MUST ASK OURSELVES "WHY?"  COMMON CAUSES ARE: ISCHEMIA (DO AN ECG, THE PATIENT SHOULD HAVE A STRESS TEST AS ANOTHER TEST FOR ISCHEMIA), ELECTROLYTE IMBALANCE (CHECK THE LYTES - HYPERKALEMIA IS ALWAYS A FRONT RUNNER), DRUGS (ONE EXAMPLE IS RED BULL-INDUCED VT IN AN EMERGENCY NURSE WHO DRANKS 3 LARGE CANS DURING HIS 8 HOUR SHIFT).

The significance of ventricular bigeminy may be huge or of little consequence. First, it depends on how my patients looks right at this moment. Are they compromized? Some ventricular beats produce an output while others don't. So, when assessing this patient it is important to determine if there is output with these beats; otherwise what may look like a heart rate of 80 may only be one of 40. If all tests have deemed no significant cause of the bigeminy, then there is really nothing more to be done. Starting on an antiarrhythmic drug, such as amiodarone, would not be recommended as this drug may cause worse side effects that the treatment it's being given for; namely torsade des pointe from a prolongation of the QT interval.

 

Darlene Hutton, RN, BScN, MSN

 

 

 

 

Dawn's picture

Ventricular Bigeminy

Submitted by Dawn on Thu, 12/29/2011 - 21:50

This ECG is from an elderly man who is being worked up for general weakness in the Emergency Department.  Every other beat is a PVC (ventricular bigeminy).  Even though he appears to have a very slow sinus rhythm underlying the bigeminy, often the PVCs are taking the place of one of the sinus beats by occurring early in the cycle and making the ventricles refractory to the next sinus impulse. If you look carefully at leads that show P waves well, like II and III in this case, you will see a slight disturbance in the T wave of the PVC, marking where the sinus P wave occurs.  Try marching out the P waves you can see, and look for the hidden P waves at the halfway point between them.

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