Ventricular Bi & Trigeminy

PVCs are a fairly normal thing.  Sitting right here typing this out, I felt one, it’s kind of like your heart skips a beat.  Usually they are benign, but when you have sustained bursts of sequential runs of PVCs as a nurse we need to do some research and know the reasons why your patient is having these.

First, ventricular bigeminy

click for largerIn ventricular bigeminy, every other beat is a PVC.  This is usually caused by an irritable foci within the ventricle firing early, in this case, over and over again.

Second, ventricular trigeminy.

click for largerAs you can see, every third beat is a PVC followed by a compensatory pause and then the cycle starts again.  Once again, an irritable foci within the ventricle is firing off early.

In both cases above, the PVC is followed by a compensatory pause that allows the SA node to rest the cycle.  Also, it appears that in each case, it is a single irritable foci that is firing as the complexes are the same in each strip.  Among the causes of PVCs are:  ischemia, hypoxia, hypokalemia, hypomagnesemia, hypercalcemia, digoxin, cocaine, alcohol, tobacco, cardiomyopathy, MI, mitral valve prolapse and several others.   One of the old school nurses I worked with was saying how back in the day, anytime a patient had more than 6 PVCs a minute, they got started on a lidocaine drip.  Not so much anymore.

If this were my patient, I would double check to make sure they’re maintaining a blood pressure and feeling OK, then make sure their electrolytes get checked.   That is assuming there wasn’t some sort of event, like an MI, occurring.  Typically treatment is either treat the underlying problem, like repleting electrolytes, or do nothing.  Antiarrhythmic medications typically are not used as the side effects can be worse than the problem they are trying to treat!  (See info on the CAST trial for a good illustration.)

The key comes down to this:  how does your patient look?  As with many arrhythmias, sometimes the true measure of what the squiggly lines are saying about your patient is what you patient is telling you.  If they’re doing just fine, then no worries, if not, you need to do some digging!

eMedicine: Prematue Ventricular Contraction

Wikipedia: Premature Ventricular Contraction



  1. I was diagnosed to have trigeminy, the doctors
    have giving me no meds. I can see my t-shirt
    go up and down, I am so afraid, I have to see
    the doc. in August, what can I do?
    What or if any meds should I take?
    Can you help me? Is there another test that
    I should have?
    Please write back
    Thank you.


    1. I hate to pass the buck, but this is something that you really need to discuss with your doctor. The only advice I can offer is to be honest with them about your concerns and to ask for information related to the condition and your particular situation. Sorry I can’t be of more help.


  2. I was diagnosed with:

    Palpitations – with ventricular trigeminies with stable morphology and no malignant ventricular arrhythmias seen

    My doctor told me my heart occassionally skips a beat, I can feel when it happens which is why I was on a monitor for 30 days to record when I felt them. He prescribed propranolol hcl 10mg to use as needed for palpitations if they become bothersome. I see him again in 4 months. Normal stress test with doppler imaging. Family history of heart disease.

    Is this anything that I need to be worried about? Can this cause a heart attack? He told me I have nothing to worry about but why the followup in 4 months? Is this normal to be followed up on like this?


    1. If you’re uncomfortable with what your doc has proposed, you need to take it up with him – it’s part of being a patient to ask questions like this of your doc. That said, this site is not meant to dispense medical advice. Sorry. At least you’re getting follow-up…


  3. I have had two episodes, about 6 months apart, where I am driving down the road and start to feel strange in my head and cannot breathe at all. The first time it happened my eyesight was fading in and out. It is extremely terrifying. I have been able to pull over both times. These episodes seem to be followed by a couple of much less significant “aftershocks” in the days that follow. I usually just get that strange feeling in my head and a little short of breath during the “aftershocks.” I have been seeing a cardiologist since the first episode happened in July 2009. He says I have PVCs and skipped beats but cannot find anything else wrong. He says that he cannot explain these episodes as having anything to do with my heart. He also says that unless we “catch” an episode on the monitor, then he has no clue what is going on. I have worn the two-week telephonic monitor two times. I did not have an episode either time. This has only happened twice: once in July 2009 and once in January 2010. I get very upset just thinking that this could happen again at any moment and nobody can tell me what it is or what can be done about it. I really feel like I am checking out of this world when it happens and fear I will not be able to regain my ability to breathe the next time. I try not to think about it. The first time it happened, I was taken by ambulance to the hospital where they found nothing wrong. They did an EKG, cardiac enzymes, D dimer to check for a blood clot but all came back normal. I am totally baffled and am going to see a neurologist to see if this could be explained neurologically. I will go to specialist after specialist if I have to. Someone has to know what this is and what to do about it before it is too late. I am 41 years old. I do not smoke nor have I ever. I might drink twice a year at most. I do not take drugs of any kind. I drink caffiene free drinks for the most part. I would say I have caffience containing drinks 3-5 times a week.


    1. Hi Christen, I had a similar experience. After a mega work-up including stress test, echo , 30 day monitor , head ct, Gyn, endocrine, neuro, and GI workup, we are left with the diagnosis of anxiety/panic. Very common esp with driving. I have never been a nervous anxious person but this past summer was particularly stressful and maybe I finally just broke!! Anyway, I feel much better now just with time and family support. All the medical tests made it difficult to forget and move on from the terrifying experience. I am glad the tests are over and it is so reassuring to know thwy were all normal. Focus on the positive! You made need a some meds short term to get over your traumatic experience and break that cycle of fear and anxiety. Good lusk–you WILL feel better!!!


      1. I won’t be approving anymore comments on this post. Like I said earlier, this site is NOT a place to diagnose, treat or otherwise give medical advice on this or any other topic . Sorry to be a wet blanket, but I have to protect myself, may family and my license. Like said before: The only advice I can offer is to be honest with them(your doctors) about your concerns and to ask for information related to the condition and your particular situation. That’s all. Thank you.

  4. I’ve been told by my doctor that I have both BY & TRYgeminy hart beats. I did a 24hr. monitor system and was told I had 35,500 BY & trygeminy beats in a 24hr. period. The doctor told me he wanted to do surgery because I had a bad reaction to medication treatment. Can someone tell me how serious this opperation will be?


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