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PVC couplet

Two PVCs in a row. Three or more in a row is a run of ventricular tachycardia.

A 6-second EKG rhythm strip showing PVC couplet.
PVC couplet, 6 seconds of strip. Each small box is 0.04 seconds and each large box is 0.20 seconds.
Try the 60-second rhythm challenge →

How to identify PVC couplet

Rate
That of the underlying rhythm
Rhythm
Regular, interrupted by a pair of early beats
P waves
None before the PVCs
PR interval
Normal on the sinus beats
QRS
The paired early beats are wide
Clincher
Two PVCs in a row. Three or more in a row is a run of V-tach.

Rhythms it gets mistaken for

  • PVC couplet vs Unifocal PVCs

    PVC couplet has two early beats in a row. With unifocal PVCs you would see a regular rhythm interrupted by early beats. How to spot unifocal PVCs: Early, wide beats that all look alike, with a T wave pointing opposite the QRS and a compensatory pause.

  • PVC couplet vs Multifocal PVCs

    PVC couplet has wide complexes that all look alike. With multifocal PVCs you would see wide early beats of more than one shape. It also has two early beats in a row, while multifocal PVCs would show a regular rhythm interrupted by early beats. How to spot multifocal PVCs: PVCs of more than one shape: more than one irritable spot.

  • PVC couplet vs Ventricular tachycardia (monomorphic)

    PVC couplet has a P wave before each normal beat and no P wave in front of the early beats. With V-tach you would see no upright P wave in front of the QRS. It also has narrow beats with wide early beats mixed in, while V-tach would show a wide QRS, 0.12 s or more. It also has two early beats in a row, while V-tach would show a regular rhythm. How to spot V-tach: Wide, fast and regular. If you cannot classify it, assume V-tach.

Treatment by certification level

Open your level. Treat the patient, not the strip.

Paramedic

Treat the cause and monitor.

  • No prophylactic antiarrhythmic for isolated ectopy, even in acute coronary syndrome. Treat the ischemia and watch the rhythm.
  • Watch for the patterns that matter: R-on-T, couplets, multiformed, frequent uniform, bigeminy.
AEMT

Pulse present and stable.

  • Oxygen only if hypoxic or short of breath, IV access, monitoring.
  • Acquire and transmit a 12-lead ECG. Interpreting it is a Paramedic skill.
  • Transport and reassess. Request a paramedic if the patient worsens.
EMT

Pulse present: assess and support.

  • Treat the patient, not the rhythm name: airway, breathing, circulation, vital signs.
  • Oxygen if the SpO2 is under 94%, the patient is short of breath, or shows signs of shock.
  • Request ALS and transport promptly. Reassess on the way.

An AED goes only on a patient who is unresponsive, not breathing and pulseless. It cannot feel a pulse, so on a patient with a pulse it can advise a shock that would do harm.

Could you pick out PVC couplet on a fresh strip? See how many rhythms you can identify in one minute.

Try the 60-second rhythm challenge