What is the diagnosis and treatment for ventricular bigeminy (premature ventricular contractions occurring in an alternating pattern)?

From the Guidelines

Ventricular bigeminy should be managed based on symptoms and underlying heart health, with consideration of catheter ablation or antiarrhythmic medications like amiodarone for symptomatic patients with left ventricular dysfunction, as recommended by the 2015 ESC guidelines 1.

Key Considerations

• Ventricular bigeminy is a cardiac rhythm pattern where every normal heartbeat is followed by a premature ventricular contraction (PVC), creating an alternating pattern.
• Treatment depends on symptoms and underlying heart health, with asymptomatic patients with no structural heart disease typically requiring only regular monitoring.
• For symptomatic patients, especially those with left ventricular dysfunction, catheter ablation should be considered, as it can suppress PVCs and restore LV function, according to the 2015 ESC guidelines 1.
• Antiarrhythmic medications like amiodarone may also be considered for symptomatic patients, particularly those with frequent symptomatic PVC or NSVT, as recommended by the 2015 ESC guidelines 1.

Management Strategies

• Addressing underlying causes is crucial, including correcting electrolyte abnormalities (particularly potassium and magnesium), reducing caffeine and alcohol intake, managing stress, and treating any underlying heart disease.
• Patients should seek immediate medical attention if bigeminy is accompanied by dizziness, fainting, chest pain, or shortness of breath.
• The mechanism involves early activation of the ventricles from an ectopic focus, disrupting the normal cardiac cycle and potentially affecting cardiac output if frequent enough.

Recent Guidelines

• The 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death also highlights the importance of evaluating and managing underlying conditions that may contribute to PVCs and NSVT 1.
• However, the most recent and highest quality study, the 2015 ESC guidelines, prioritizes catheter ablation and antiarrhythmic medications like amiodarone for symptomatic patients with left ventricular dysfunction 1.

From the FDA Drug Label

Flecainide acetate tablets, USP cause a dose-related and plasma-level related decrease in single and multiple PVCs and can suppress recurrence of ventricular tachycardia The answer to Ventricular bigeminy is that flecainide can suppress PVCs, which may include ventricular bigeminy, but the label does not directly address ventricular bigeminy. 2

From the Research

Definition and Treatment of Ventricular Bigeminy

• Ventricular bigeminy is a type of arrhythmia characterized by the alternation of premature ventricular complexes (PVCs) with normal beats 3.
• The treatment of ventricular bigeminy often involves the use of anti-arrhythmic medications, such as flecainide, which has been shown to be effective in reducing PVCs and other ventricular arrhythmias 3.

Efficacy of Flecainide in Treating Ventricular Arrhythmias

• A study published in the European Heart Journal in 1984 found that flecainide reduced PVCs by more than 85% in 47 patients with chronic ventricular arrhythmias 3.
• The study also found that flecainide reduced repetitive ventricular beats and ventricular tachycardia by more than 76% and 79%, respectively, throughout the follow-up period 3.
• The efficacy of flecainide was maintained despite a gradual reduction in dosages and plasma levels, suggesting that the medication can be effective at lower doses 3.

Potential Side Effects and Complications

• While flecainide was generally well-tolerated, some patients experienced subjective side effects, and two patients developed reversible heart failure and sinus node dysfunction 3.
• Four patients with underlying severe coronary artery disease or cardiomyopathy developed lethal arrhythmias or ischemic events during the study period, highlighting the importance of careful patient selection and monitoring 3.