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Ventricular Ectopic Beats

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Insights into Electrocardiograms with MCQs

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Abstract

Electrocardiogram is helpful in differentiating a supraventricular ectopic beat with aberrant intraventricular conduction from a ventricular ectopic beat. This is important from the point of view of diagnosis of diseased cardiac chamber. Premature ventricular beat also needs to be differentiated from an escape ventricular beat because the latter does not need suppression. Electrocardiogram is also useful in deciding the most probable site of origin of a premature ventricular beat. This helps the electrophysiologist in targeting their approach. Electrocardiogram also helps in deciding the seriousness of premature ventricular beats. This is important in decision to start an antiarrhythmic agent or refer the patient to an electrophysiologist for ablation. Morphology of the T wave or the U wave of the sinus beat following a premature ventricular beat can give some impression about underlying myocardial ischemia. All these findings are discussed with their clinical significance and representative electrocardiograms. Summary and MCQs at the end of the chapter help in quick revision and self-assessment.

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References

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Author information

Authors and Affiliations

  1. Ex Senior professor and head of the department of cardiology, Jawaharlal Nehru Medical College, Ajmer, India

    Sitaram Mittal

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  1. Sitaram Mittal
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Appendices

Summary

  • Premature ventricular complexes (PVC) are broad complexes occurring earlier than the scheduled sinus beat. The T wave is broad and is in the opposite direction.

  • Premature ventricular contractions are not preceded by an abnormal P wave. However, late occurring PVC may follow a sinus P wave with no or short PR segment.

  • Retrograde conduction to atria can produce a negative P wave deforming the ST segment or the T wave of the premature ventricular conduction.

  • Coupling interval from previous sinus beat may be fixed or variable. Uniform premature ventricular contraction with variable coupling interval but having mathematical distance from each other is known as parasystole and suggests increased automaticity as the underlying mechanism.

  • Premature ventricular contraction may be interpolated or may have incomplete or complete compensatory pause. Compensatory pause does not help in differentiating premature ventricular contraction from supraventricular ectopics.

  • In interpolated premature ventricular contraction, next sinus P wave is conducted with mild prolongation of the PR interval due to partial refractoriness of the atrioventricular node by retrograde conduction of premature ventricular contraction.

  • When a premature ventricular contraction is followed by a retrograde P wave which returns back to excite the ventricle after mildly increased PR interval, it is known as an “echo beat.”

  • Premature ventricular contraction usually has a duration of 120 msec or more. However, it may not be so wide if:

    • There is fusion of a late occurring premature ventricular contraction with the next sinus beat.

    • Premature ventricular contraction arises from the ventricle showing bundle branch block in resting ECG.

    • Premature ventricular contraction arises at a higher point equidistant from both bundle branches.

  • Alternating sinus beat and premature ventricular contraction is called “bigeminy.” Two sinus beats followed by a premature ventricular contraction is called “trigeminy.” Premature ventricular contraction following three sinus beats is called “quadrigeminy.” In contrast to their nomenclature, these patterns show decreasing frequency of premature ventricular contraction.

  • Bigeminal sequence (rule of bigeminy) does not differentiate ventricular from a supraventricular premature complex.

  • Two successive premature ventricular contractions are called “couplet.” Three successive premature ventricular contractions are called “triplet.” More than three successive premature ventricular contractions are called ventricular tachycardia. This term denotes repetitiveness of the ectopic and is more sinister than isolated ectopics.

  • Configuration of the premature ventricular contraction on the surface ECG can give a reasonable impression about the site of their origin. Left bundle branch block pattern in lead V1 with inferior axis suggests an origin in the right ventricular outflow tract. Right bundle branch block pattern suggests an origin in the left ventricle. Superior axis suggests origin in the inferior wall, whereas inferior axis suggest origin in the anterior wall. Dominant S wave in leads V3 and V4 suggests apical origin, and dominant R wave in leadsV3 and V4 suggests basal origin. Site of origin alone does not have clinical significance. Significance depends on the magnitude of structural disease in the culprit ventricle. “Multiform PVCs” need not always be “multifocal.”

  • Unifocal premature ventricular contraction (having a fixed coupling interval) can have different forms due to the different paths of conduction. Premature ventricular contraction with changing coupling interval and changing configuration which clearly define different sites of origin can be considered multifocal. Definite diagnosis may need an electrophysiologic study. Definitely multifocal premature ventricular contraction is likely to occur in more diffuse disease.

  • In an irregularly irregular rhythm, the following features suggest the possibility of a premature ventricular contraction over a supraventricular beat with aberration—short coupling interval, fixed coupling, long pause after abnormal beat, and runs of bigeminy.

  • Isolated premature ventricular contraction frequently occurs in persons without any evidence of structural heart disease. In these cases premature ventricular contraction alone does not suggest adverse prognosis and does not require antiarrhythmic therapy. Initially there was some impression that very early premature ventricular contraction (R wave of the ectopic falling on the T wave of previous beat—R on T) or very late (end-diastolic) premature ventricular contraction falling near next sinus P wave is vulnerable to trigger ventricular flutter. However, coupling interval alone may not be very relevant in the absence of any underlying risk factor for ventricular flutter. Seriousness also does not depend only on the coupling interval.

  • Premature ventricular contraction is clinically significant when they occur in the presence of structural heart disease, heart failure, or ongoing ischemia. Significance is increased in patients with cardiac diseases with increased risk of ventricular fibrillation, e.g., Brugada syndrome or long QT syndrome and short QT syndrome or idiopathic catecholaminergic polymorphic ventricular tachycardia. It is important to remember that early stages of arrhythmogenic right ventricular dysplasia may be missed on clinical examination.

  • High frequency of premature ventricular contraction occurring frequently throughout the day and premature ventricular contraction with very wide QRS complexes may be associated with increased risk of development of dilated cardiomyopathy. Regularly occurring interpolated premature ventricular contraction actually doubles the heart rate and thus causes more stress on the myocardium than premature ventricular contraction occurring as regular bigeminy.

  • Increased frequency of premature ventricular contraction during exercise stress test or during recovery may also be associated with increased risk of catecholaminergic polymorphic ventricular tachycardia.

  • New appearance or increased frequency during recovery following an exercise stress test may suggest underlying myocardial ischemia.

MCQs

Q1. A broad QRS with normal PR interval, rsR’ pattern in lead V1, and qRS pattern in lead V6 suggests:

  1. (a)

    Premature ventricular complex

  2. (b)

    Supraventricular premature beat with aberration

  3. (c)

    Supraventricular premature beat with preexcitation

  4. (d)

    All

Q2. Which electrocardiographic factures of a wide QRS complex support the diagnosis of a premature ventricular contraction?

  1. (a)

    Initial deflection identical to that of the sinus beat

  2. (b)

    P wave with normal PR interval precedes the wide QRS complex

  3. (c)

    Rr’ complex in lead V1

  4. (d)

    Interval between the P wave preceding the wide QRS complex and the P wave following the broad QRS complex is equal to the interval between three preceding sinus beats

Q3. Which electrocardiographic finding in an irregular rhythm with one broad QRS complex supports the diagnosis of a premature ventricular contraction?

  1. (a)

    RR interval of the sinus cycle preceding the broad QRS complex is shorter than the interval between the preceding narrow QRS and the broad QRS complex (short cycle-long cycle sequence)

  2. (b)

    There is a long-short cycle sequence

  3. (c)

    Other similar long-short cycle sequence in the rhythm strip is not followed by a broad QRS

  4. (d)

    There is no relatively longer pause after the wide QRS

Q4. PR interval of the sinus beat following an interpolated premature ventricular contraction is:

  1. (a)

    Normal

  2. (b)

    Reduced

  3. (c)

    Increased

  4. (d)

    Any one of above

Q5. Which of the following findings in lead V1 suggest left ventricular origin of a ventricular ectopic beat?

  1. (a)

    Rr’ configuration

  2. (b)

    rSR’ configuration

  3. (c)

    rS configuration

  4. (d)

    QS configuration

Q6. Which electrocardiographic findings suggest right ventricular origin of a premature ventricular contraction?

  1. (a)

    Wide r followed by S in lead V1

  2. (b)

    R or rR’ in lead V6

  3. (c)

    rS or QS deeper in lead V4 than in lead V1

  4. (d)

    rsR’ in lead V1

Q7. Premature ventricular contraction with left bundle branch block configuration and inferior axis suggests origin in:

  1. (a)

    Right ventricular outflow tract

  2. (b)

    Left ventricular outflow tract

  3. (c)

    left ventricular apex

  4. (d)

    Left anterior fascicle

Q8. Premature ventricular contraction with right bundle branch block configuration with left axis suggests origin in:

  1. (a)

    Right ventricular outflow tract

  2. (b)

    Left posteroinferior fascicle

  3. (c)

    Left anterosuperior fascicle

  4. (d)

    Left ventricular outflow tract

Q9. Premature ventricular contraction with right bundle branch block configuration and right axis suggests origin in:

  1. (a)

    Right ventricular outflow tract

  2. (b)

    Left ventricular apex

  3. (c)

    Left posteroinferior fascicle

  4. (d)

    Left anterosuperior fascicle

Q10. A premature ventricular beat can have:

  1. (a)

    Preceding sinus beat

  2. (b)

    QRS duration less than 120 milliseconds

  3. (c)

    Incomplete compensatory pause

  4. (d)

    T wave concordant to major deflection of QRS

Q11. A premature ventricular contraction can have incomplete compensatory pause if there is:

  1. (a)

    Retrograde conduction to the atria and the sinus node

  2. (b)

    No retrograde conduction to the atria and the sinus node

  3. (c)

    Ventricular echo beat

  4. (d)

    Interpolated premature ventricular contraction

Q12. In the presence of a bundle branch block in sinus rhythm, premature ventricular contraction can be narrow if premature ventricular contraction arises:

  1. (a)

    From the ventricle having bundle branch block

  2. (b)

    From the ventricle opposite to the side of bundle branch block

  3. (c)

    From higher point in the interventricular septum

  4. (d)

    None

Q13. A combination of sinus P wave, short PR interval, and broad QRS can occur if:

  1. (a)

    Sinus beat conducts through as accessory pathway

  2. (b)

    Premature ventricular beat follows onset of a sinus P wave

  3. (c)

    There is atrial ectopic with aberrant conduction

  4. (d)

    There is retrograde conduction of a premature ventricular beat

Q14. Trigeminy means:

  1. (a)

    Two sinus beats followed by one premature ventricular beat

  2. (b)

    Two premature ventricular beat following one sinus beat

  3. (c)

    One premature ventricular beat following three sinus beats

  4. (d)

    Three premature ventricular beat following one sinus beat

Q15. A premature ventricular beat is suspected to be parasystolic if:

  1. (a)

    Premature ventricular beat is multiformic

  2. (b)

    Premature ventricular beat occurs in couplet

  3. (c)

    Coupling interval between preceding sinus beat and the premature ventricular beat is variable

  4. (d)

    Interval between consecutive premature ventricular beat is multiple of some interval

Q16. Premature ventricular beat may be serious if they:

  1. (a)

    Have variable coupling

  2. (b)

    Are multiformic

  3. (c)

    Occur as “triplet”

  4. (d)

    Fall on top of the preceding T wave

Q17. Premature ventricular beat can be serious if they occur:

  1. (a)

    As trigeminy

  2. (b)

    With long coupling interval

  3. (c)

    In the presence of ongoing myocardial ischemia

  4. (d)

    In the presence of heart failure

Q18. Which electrocardiographic feature of a premature ventricular beat may be associated with development of cardiomyopathy?

  1. (a)

    Duration of premature ventricular beat >0.16 second

  2. (b)

    Very frequent premature ventricular beat

  3. (c)

    Interpolated premature ventricular beat

  4. (d)

    None

Q19. Very wide QRS of a premature ventricular beat may be seen in:

  1. (a)

    Myocarditis

  2. (b)

    Cardiomyopathy

  3. (c)

    Extensive myocardial infarction

  4. (d)

    Hypokalemia

Q20. New appearance of premature ventricular beats in a patient with heart failure receiving diuretic beta-blocker, ACE inhibitors, and digitalis should raise suspicion of:

  1. (a)

    Digitalis overdose

  2. (b)

    Inadequate dose of beta-blocker

  3. (c)

    Underdose of ACE inhibitors

  4. (d)

    Hypokalemia

Answers

(1) b; (2) c, d; (3) a, c; (4) c; (5) a; (6) a, b, c; (7) a; (8) b; (9) d; (10) a, b, c; (11) a, c, d; (12) a; (13) a, b; (14) a; (15) c, d; (16) a, c, d; (17) c, d; (18) a, b; (19) a, b, c; (20) a, d

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Mittal, S. (2023). Ventricular Ectopic Beats. In: Insights into Electrocardiograms with MCQs. Springer, Singapore. https://doi.org/10.1007/978-981-99-0127-2_16

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  • DOI: https://doi.org/10.1007/978-981-99-0127-2_16

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  • Publisher Name: Springer, Singapore

  • Print ISBN: 978-981-99-0126-5

  • Online ISBN: 978-981-99-0127-2

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