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Ventricular bigeminy

Also called bigeminal PVCs.

Every other beat is a PVC: normal, PVC, pause, normal, PVC, pause. Each PVC is coupled to the sinus beat before it at the same interval.

A 6-second EKG rhythm strip showing Ventricular bigeminy.
Ventricular bigeminy, 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 Ventricular bigeminy

Rate
That of the underlying rhythm
Rhythm
Regularly irregular, in pairs
P waves
Before every sinus beat, none before the PVC
PR interval
Normal on the sinus beats
QRS
Every other beat is wide
Clincher
Normal, PVC, pause, normal, PVC, pause.

Rhythms it gets mistaken for

  • Ventricular bigeminy vs Unifocal PVCs

    Ventricular bigeminy has an early beat after every normal beat. 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.

  • Ventricular bigeminy vs PVC couplet

    Ventricular bigeminy has an early beat after every normal beat. With a PVC couplet you would see two early beats in a row. How to spot a PVC couplet: Two PVCs in a row. Three or more in a row is a run of V-tach.

  • Ventricular bigeminy vs Multifocal PVCs

    Ventricular bigeminy has wide complexes that all look alike. With multifocal PVCs you would see wide early beats of more than one shape. It also has an early beat after every normal beat, 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.

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 Ventricular bigeminy on a fresh strip? See how many rhythms you can identify in one minute.

Try the 60-second rhythm challenge