1. The ECG shows a 45-year-old diabetic man with episodes of palpitations who presents with ventricular trigeminy. 2. Ventricular trigeminy is characterized by ventricular premature beats occurring after every two normal sinus beats with a compensatory pause. 3. Further investigation with Holter monitoring is recommended to better characterize the ventricular arrhythmia and assess for underlying cardiac disease.

1. Prof .Dr.K.H.NOORUL AMEEN’S unit M6 Dr.G ARUN KUMAR ECG OF THE WEEK

2. 45 YEAR OLD DIABETIC PRESENTED TO OPD WITH EPISODES OF PALPITATION ON AND OFF FOR 6 MONTHS NO H/O CHEST PAIN , SYNCOPE NO H/O ANY DRUG INTAKE(BUT FOR OHA)

5. Lead 2 rhythm strip

6. Whats the diagnosis ? Whats the next investigation you would do ? Drugs causing this pattern?

7. RATE – 88/MIN RHYTHM – REGULARLY IRREGULAR P WAVE - NORMAL MORPHOLOGY PR INTERVAL – 180 ms QRS NORMAL IN SINUS BEAT BUT WIDE AND BIZZARE AFTER EVERY 2 NORMAL SINUS BEAT(VENTRICULAR ECTOPIC) RBBB PATTERN

8. IMP: VENTRICULAR PREMATURE BEAT WITH COMPLETE COMPENSATORY PAUSE (VENTRICULAR TRIGEMINY) PROBABLY OF LEFT VENTRICULAR ORIGIN NORMAL RR INTERVAL 720 ms 2 TIMES RR INTERVAL ( pre ectopic + post ectopic interval = 2 sinus interval ) 1440ms COMPENSATORY PAUSE

9. VENTRICULAR PREMATURE BEAT THEY ARE PREMATURE AND OCCUR BEFORE NEXT NORMAL BEAT IS EXPECTED THEY ARE USUALLY WIDE , BIZZARE IN APPEARANCE DUE TO THEIR ECTOPIC FOCUS AND THE COURSE OF DEPOLARISATION IS ALSO ABNORMAL THE T WAVE AND QRS COMPLEX POINT IN OPPOSITE DIRECTION

10. RELATION TO SINUS P WAVE VENTRICULAR EXTRASYSTOLE MAY MANIFEST 1 . BEFORE THE FOLLOWING SINUS DISCHARGE 2. AT THE TIME OF SINUS DISCHARGE 3. RELATIVELY LATE ie AFTER SINUS P WAVE BUT BEFORE THE NORMAL QRS ( END DIASTOLIC VENTRICULAR ES). SOMETIMES THIS TYPE OF IMPULSES INVADE THE VENTRICLES AT THE SAME TIME AS SINUS IMPULSE THEREBY RESULTING IN A VENTRICULAR FUSION BEAT 4.RETROGRADE CONDUCTION OF VENTRICULAR EXTRASYSTOLE PRODUCE A PREMATURE INVERTED P WAVE FOLLOWING A WIDE QRS

11. FREQUENCY WHEN ISOLATED VPBs ARISE AFTER EVERY SINUS BEAT- VENTRICULAR BIGEMINY WHEN ISOLATED VPBs ARISE AFTER EVERY 2 SINUS BEATS- VENTRICULAR TRIGEMINY VPBs OCCURING 2 IN A ROW – PAIR OR COUPLET VPBs OCCURING 3 OR MORE IN A ROW - VT

12. VENTRICULAR BIGEMINY

13. COUPLET

14. MORPHOLOGY LV ORIGIN - RBBB PATTERN RV ORIGIN - LBBB PATTERN IVS ORIGIN - LBBB PATTERN COUPLING INTERVAL INTERVAL BETWEEEN ECTOPIC BEAT AND PRECEEDING SINUS BEAT(IS SAME FOR VPBs ARISING FROM SAME FOCUS)

15. INTERPOLATED VENTRICULAR EXTRASYSTOLE THIS TYPE OCCURS 1. WITHOUT A COMPENSATORY PAUSE 2.DURING SLOW SINUS RHYTHM 3.SINUS BEAT FOLLOWING THE ES HAS A LONGER PR INTERVAL

16. UNIFORM AND MULTIFORM VPB MULTIFOCAL VENTRICULAR EXTRASYSTOLES AND EXTRASYSTOLES IN PAIRS ARE ALWAYS ABNORMAL UNIFOCAL VENTRICULAR EXTRAYSTOLES ARE USUALLY INDICATIVE OF CARDIAC DISEASE IF OCCURS IN CROPS IF THEY OCCUR IN BIGEMINAL RHYTHM IF THEY OCCUR IN ASSO. CARDIAC DISEASE IF AGE >40 IF THEY ARE PRECIPITATED BY EXERCISE

17. R ON T PHENOMENON VPBs THAT FALL ON THE PEAK OF T WAVE OF SINUS BEAT MAY PRECIPITATE VT OR VF. THIS USUALLY OCCUR WITH VPBs WITH SHORT COUPLING INTERVAL WHICH ALMOST OCCUR IN THE SETTING OF ANY ACUTE INSULT TO HEART (eg ACUTE MI)

18. CAUSES OF VPB ANXIETY EXCESS CAFFEINE INTAKE AMINOPHYLLINE EPINEPHRINE ISOPROTERENOL DIGITALIS(V.BIGEMINY) VALVULAR,HYPERTENSIVE,ISCHEMIC HEART DISEASE ACUTE MI HYPOKALEMIA,HYPOMAGNESIMIA, HYPOXEMIA OF ANY CAUSE

19. GRADING

20. CLINICAL FEATURES ASYMPTOMATIC PALPITATIONS,MISSED OR EXTRA BEAT TREATMENT USE OF ANTIARRHYTHMICS IN ISOLATED VPBs AND SHORT RUN VT HAVE NOT SHOWN ANY IMPROVED SURVIVAL USE OF BETA BLOCKERS HAS BEEN HELPFUL IN ABOLISHING VPBs IN PATIENT WITH STEMI AND IN PREVENTION OF VF AT PRESENT PHARMACOTHERAPY IS RESERVED ONLY FOR PATIENT WITH SUSTAINED VENTRICULAR ARRHYTHMIAS USE OF PROPHYLACTIC ANTI ARRHYTHMICS IS CONTRAINDICATED IN THE ABSENCE OF CLINICALLY IMPORTANT VT

21. THANK YOU REF : SHAMROTH GOLDBERGER HARRISON