From the Guidelines
Ventricular bigeminy is generally not recommended to be treated with antiarrhythmic medications, except in cases where patients are symptomatic or have underlying heart disease, in which case beta-blockers or catheter ablation may be considered. Ventricular bigeminy is a cardiac arrhythmia characterized by a pattern where every normal heartbeat is followed by a premature ventricular contraction (PVC), creating a repetitive pattern of normal beat-PVC-normal beat-PVC. The presence of PVCs, including those in a bigeminy pattern, has been associated with increased risk of adverse cardiovascular outcomes, including ischemic heart disease events and mortality, particularly in patients with underlying heart disease 1.
For asymptomatic patients without structural heart disease, no specific treatment is typically needed beyond regular monitoring, as the risk of adverse outcomes is lower in this population. However, for symptomatic patients or those with underlying heart disease, a comprehensive cardiac evaluation including ECG, echocardiogram, and possibly Holter monitoring is recommended to assess the underlying cause of the ventricular bigeminy and to guide treatment.
Treatment options for symptomatic patients may include beta-blockers, such as metoprolol (25-100 mg twice daily), which can help reduce symptoms by decreasing the heart rate and contractility, or catheter ablation, which can be effective in eliminating the PVCs and improving symptoms in patients with frequent and symptomatic PVCs or non-sustained ventricular tachycardia (NSVT) 1. Addressing underlying causes is also essential, including correcting electrolyte abnormalities (particularly potassium and magnesium), reducing caffeine and alcohol intake, managing stress, and treating any underlying heart disease.
It's worth noting that the use of antiarrhythmic medications, such as flecainide, has not been shown to reduce mortality and may even increase the risk of death in certain populations, such as post-myocardial infarction patients 1. Therefore, these medications should be used with caution and only in patients who are symptomatic and have failed other treatments. Overall, the management of ventricular bigeminy should be individualized based on the patient's symptoms, underlying heart disease, and other factors, with a focus on reducing symptoms and preventing adverse cardiovascular outcomes.
From the FDA Drug Label
PROARRHYTHMIC EFFECTS Flecainide acetate, like other antiarrhythmic agents, can cause new or worsened supraventricular or ventricular arrhythmias. In patients treated with flecainide for sustained ventricular tachycardia, 80% (51/64) of proarrhythmic events occurred within 14 days of the onset of therapy In studies of 225 patients with supraventricular arrhythmia (108 with paroxysmal supraventricular tachycardia and 117 with paroxysmal atrial fibrillation), there were 9 (4%) proarrhythmic events, 8 of them in patients with paroxysmal atrial fibrillation Of the 9,7 (including the one in a PSVT patient) were exacerbations of supraventricular arrhythmias (longer duration, more rapid rate, harder to reverse) while 2 were ventricular arrhythmias, including one fatal case of VT/VF and one wide complex VT
Ventricular bigeminy is not directly mentioned in the provided drug labels as a specific condition that can be caused or worsened by flecainide acetate. However, the labels do mention that flecainide can cause new or worsened ventricular arrhythmias, including an increase in frequency of PVCs 2. It is uncertain if flecainide acetate’s risk of proarrhythmia is exaggerated in patients with chronic atrial fibrillation (CAF), high ventricular rate, and/or exercise 2. Flecainide acetate can suppress recurrence of ventricular tachycardia and cause a dose-related and plasma-level related decrease in single and multiple PVCs 2. The labels also mention that flecainide is not recommended for use in patients with chronic atrial fibrillation due to the risk of ventricular pro-arrhythmic effects 2.
Given the information provided, it is not possible to draw a direct conclusion about the relationship between flecainide acetate and ventricular bigeminy.
From the Research
Definition and Treatment of Ventricular Bigeminy
- Ventricular bigeminy is a type of bigeminal rhythm that involves ectopic firing, usually requiring treatment with suppressive drugs 3.
- It is characterized by a premature ventricular complex (PVC) following each sinus beat, and may be coupled to sinus beats or accompany atrial fibrillation.
Medical Therapy for Ventricular Bigeminy
- The effectiveness of medical therapy for ventricular bigeminy is uncertain, but studies have shown that Class I and III antiarrhythmic drugs (AADs) have superior effectiveness in reducing PVCs compared to beta-blockers or calcium channel blockers (BBs/CCBs) 4.
- Beta-blockers, such as bisoprolol, have been shown to be effective in treating supraventricular and ventricular arrhythmias, including ventricular bigeminy 5.
- The use of beta-blockers as antiarrhythmic agents has been supported by several studies, which have shown a reduction in sudden death and ventricular arrhythmias with beta-blocker treatment 6, 7.
Clinical Implications of Ventricular Bigeminy
- Ventricular bigeminy has the same clinical implications as concealed bigeminy, which is manifested as PVCs separated by an odd number of sinus beats 3.
- The identification of the mechanism of bigeminal rhythm is crucial for making clinical decisions, as different types of bigeminy may require different treatments 3.
- The treatment of ventricular bigeminy should be individualized based on the patient's symptoms, cardiac function, and underlying heart disease 4.