What is the treatment for symptomatic ventricular bigeminy (premature ventricular contractions occurring in an alternating pattern) with bradycardia (abnormally slow heart rate)?

From the Guidelines

Treatment of symptomatic ventricular bigeminy with bradycardia should prioritize addressing the slow heart rate, with first-line treatment involving atropine 0.5 to 1 mg IV repeated every 3 to 5 minutes as needed up to 1.5 to 3 mg total, as recommended by the 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science 1.

Key Considerations

• The goal of treatment is to reduce symptoms while maintaining adequate heart rate and cardiac output.
• Treatment decisions should be guided by symptom severity, underlying cardiac disease, and the degree of bradycardia.
• In cases where bradycardia is the predominant concern, especially with heart rates below 40 beats per minute or pauses greater than 3 seconds, temporary pacing or permanent pacemaker implantation may be necessary, as outlined in the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay 1.

Treatment Options

• Atropine is the first-line treatment for symptomatic bradycardia, with a dose of 0.5 to 1 mg IV repeated every 3 to 5 minutes as needed up to 1.5 to 3 mg total 1.
• If atropine is not effective, consider epinephrine (2 to 10 µg/min) or dopamine (2 to 10 µg/kg/min) as second-line treatments 1.
• Temporary pacing may be considered when full-dose atropine fails, although it may not be any more effective than second-line drug therapy 1.
• Permanent pacemaker implantation may be required in cases where bradycardia is the predominant concern, especially with heart rates below 40 beats per minute or pauses greater than 3 seconds 1.

From the FDA Drug Label

Atropine abolishes various types of reflex vagal cardiac slowing or asystole The drug also prevents or abolishes bradycardia or asystole produced by injection of choline esters, anticholinesterase agents or other parasympathomimetic drugs, and cardiac arrest produced by stimulation of the vagus. Atropine also may lessen the degree of partial heart block when vagal activity is an etiologic factor In some patients with complete heart block, the idioventricular rate may be accelerated by atropine; in others, the rate is stabilized.

Treatment of symptomatic ventricular bigeminy with bradycardia may involve the use of atropine, as it can abolish vagal cardiac slowing or asystole and prevent or abolish bradycardia. Atropine may be used to increase heart rate in patients with symptomatic bradycardia. However, it is essential to use atropine with caution, as it may have varying effects on the heart, including accelerating the idioventricular rate in some patients with complete heart block or stabilizing the rate in others 2.

From the Research

Treatment of Symptomatic Ventricular Bigeminy with Bradycardia

• The treatment of symptomatic ventricular bigeminy with bradycardia depends on the severity of symptoms and the underlying cause of the condition 3, 4.
• For patients with symptomatic bradycardia, treatment options include pharmacologic therapy and/or pacing 4, 5.
• In the acute setting, symptomatic patients can be treated with atropine, and percutaneous pacing can be used as a bridge to definitive treatment 5.
• The only therapy for persistent bradycardia is the placement of a permanent pacemaker, which is often required for symptomatic patients with sick sinus syndrome and high second- or third-degree atrioventricular blocks 5.
• For ventricular bigeminy, treatment with suppressive drugs is usually required 6.
• Implantation of an artificial pacemaker may be appropriate in some cases, especially if the bigeminy is associated with delayed impulse conduction or other conduction abnormalities 6.

Evaluation and Management

• Evaluation of bradycardia should include a thorough history and physical examination to determine the underlying cause of the condition and to assess the severity of symptoms 4, 7.
• Assessment of symptoms is a critical component in the evaluation and management of bradycardia, and treatment should rarely be prescribed solely on the basis of a heart rate lower than an arbitrary cutoff or a pause above certain duration 7.
• The 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients with Bradycardia and Cardiac Conduction Delay emphasizes the importance of evaluating and managing disease states rather than relying solely on device-based implantation recommendations 7.