Treatment of Ventricular Bigeminy

Introduction to Treatment

The American College of Cardiology recommends that treatment for ventricular bigeminy should be based on symptom severity, cardiac function, and underlying heart disease 1
The European Society of Cardiology recommends that treatment of ventricular bigeminism should be initiated in highly symptomatic patients, with evidence of ventricular dysfunction, or when there is underlying structural heart disease 2

Beta-blockers are the first-line therapy for most patients with symptomatic ventricular bigeminy, particularly effective for controlling ventricular response, and have been shown to accelerate conversion of postoperative supraventricular arrhythmias to sinus rhythm, according to the American College of Cardiology 1, 2
Non-dihydropyridine calcium channel blockers are an alternative first-line option, especially in patients with contraindications to beta-blockers 3, 2
Flecainida, an antiarrhythmic class IC drug, can be used in the absence of structural heart disease 2

Athletes with symptomatic or exercise-induced ventricular extrasystoles should avoid participation in competitive sports, except for class IA sports, and those with cardiac channelopathies require special consideration, as per the American College of Cardiology guidelines 3, 4
Patients with heart failure should be treated with beta-blockers, which are most effective for controlling ventricular response, and avoid negative inotropic effects of some antiarrhythmics in decompensated heart failure, according to the American College of Cardiology 1
Patients with long QT syndrome should avoid medications that prolong the QT interval, and patients with Brugada syndrome should avoid medications that exacerbate the condition 4
Saxagliptina is not recommended in patients with diabetes and high risk of heart failure 2

Asymptomatic patients generally do not require treatment if no structural heart disease, but consideration should be given to treatment if PVC burden is very high (>10-15%) due to risk of developing cardiomyopathy 3
The primary goal of treatment is to improve symptoms and prevent or reverse ventricular dysfunction, as the risk of cardiac events is primarily determined by the underlying heart disease rather than the extrasystoles themselves, as recommended by the American College of Cardiology 1, 2
Catheter ablation should be considered in patients with symptoms refractory to medical treatment, intolerance to antiarrhythmic medications, or ventricular dysfunction induced by frequent extrasystoles 2

Initial evaluation should include determination of significant symptoms, assessment of ventricular function (using echocardiogram), exclusion of structural heart disease, and quantification of extrasystole burden (using 24-hour Holter monitoring) 2
Evaluation of structural heart disease should be performed using stress ECG, echocardiography, coronary angiography, or magnetic resonance imaging 2

Patients with mild symptoms and no structural heart disease can be reassured and advised to avoid triggers (e.g., caffeine, alcohol, stress), with clinical follow-up 2
Dynamic auscultation maneuvers, such as the Valsalva maneuver, position changes, and carotid sinus massage, can help identify PACs and distinguish them from other arrhythmias 5

Premature Atrial Contractions (PACs) are characterized by an "irregular rhythm" or "irregularly irregular rhythm" with a pause followed by a stronger beat, sometimes described as a "dropped beat" pattern, according to the American Heart Association 5
Atrial fibrillation is characterized by "absolutely" irregular RR intervals with no discernible pattern and absence of distinct P waves, as stated by the European Society of Cardiology 6
Patients with symptomatic PACs may cause palpitations described by patients as "skipped beats" or "fluttering", according to the American Heart Association 5