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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Comments
Ventricular bigeminy
This comment was received via email from Christopher W.
Nice 12-lead! Some other things I noticed in the strip are the ST-depression in I/aVL/V2-V6 (although V5/V6 look more like "dig" scooping), and that III has what could be ST-elevation in time (it has that "look"). RV PVCs with what could be RCA ischemic changes makes sense.
Was this from a patient with an NSTEMI/STEMI?
Dawn Altman, Admin
Ventricular bigeminy
Hi, Christopher,
From what I can remember, this patient was not complaining of chest pain, but was at the very beginning of a workup in the Emergency Department for a complaint of weakness. I believe he was on digitalis, and dig toxicity should always be considered in cases of ventricular bigeminy.
I totally agree with your observations of Lead III - not a huge elevation, but definitely, the ST segment has an abnormal shape, and could indicate early signs of injury. Add to that the depressions, which could be reciprocal or ischemic (or digitalis effect). I am sorry I don't have the follow up on this patient - that is always the best!
I would LOVE for the other ECG Gurus out there to weigh in on this interesting topic.
Dawn
Dawn Altman, Admin