From the Guidelines
Ventricular couplets are a significant cardiac arrhythmia that requires investigation as they can be a marker for underlying cardiac pathology or lead to sustained ventricular tachycardia, which may cause sudden cardiac death, as emphasized by the international recommendations for electrocardiographic interpretation in athletes 1. Key points about ventricular couplets:
- Appearance: On an ECG, they appear as two abnormal QRS complexes in a row, often wider and different in shape from normal beats.
- Significance: While isolated PVCs are often benign, couplets may indicate increased cardiac irritability and risk for more serious arrhythmias, such as short-coupled torsade de pointes, which is a rare variant of polymorphic VT of unknown aetiology 1.
- Causes: Can be triggered by stress, caffeine, alcohol, electrolyte imbalances, or underlying heart disease, and may be associated with an autonomic nervous system imbalance 1.
- Symptoms: May cause palpitations, dizziness, or shortness of breath, though some people may not feel them, and in some cases, may present with unclear syncope and a positive family history for SCD 1.
- Management: Often involves addressing underlying causes and may require antiarrhythmic medications, such as intravenous verapamil, or catheter ablation in some cases, and ICD implantation is strongly recommended in patients with short-coupled TdP 1. If experiencing frequent ventricular couplets, patients should seek medical evaluation to determine the underlying cause and assess the need for treatment, as early investigation and management are crucial to prevent sudden cardiac death and improve quality of life. Lifestyle modifications like reducing caffeine and alcohol intake, managing stress, and treating any underlying heart conditions are often the first steps in management.
From the Research
Definition and Characteristics of Ventricular Couplets
- Ventricular couplets refer to premature ventricular contractions (PVCs) that occur in pairs 2
- PVCs are early depolarizations of the myocardium originating in the ventricle 3
- They can be benign or a sign of underlying cardiac disease, and may cause significantly impairing symptoms 4
Clinical Significance of Ventricular Couplets
- Ventricular couplets can be a marker of electrocardiomyopathy and may increase the risk for sustained ventricular tachycardia, ventricular fibrillation, and sudden cardiac death 5
- The frequency and complexity of PVCs, including couplets, can be associated with mortality, especially in ischemic heart disease 3
- In some cases, PVCs, including couplets, can cause tachycardia-induced cardiomyopathy in patients without preceding structural heart disease 5
Diagnosis and Treatment of Ventricular Couplets
- Diagnosis of ventricular couplets involves electrophysiological testing and imaging studies to determine the origin and characteristics of the PVCs 2
- Treatment options for ventricular couplets include medical therapy, such as beta-blockers and class III anti-arrhythmic agents, as well as invasive catheter ablation 5, 6
- Implantable cardiac defibrillators (ICD) may be indicated in certain patients with ventricular couplets and other risk factors for sudden cardiac death 5, 3