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Tuesday, 22 January 2013

All about Ventricular Ectopics

Ventricular Ectopics (VE's)

#ECGclass Case 21 (previous post) shows an example of Ventricular Bigeminy. This occurs when sinus beats alternate with a Ventricular Ectopic (VE) beat.

You may also here people refer to VE beats as PVC's (Premature Ventricular complexes) or VPB's (Ventricular Premature Beats).
Don't let these different acronyms throw you. They all mean the same thing.

VE's arise earlier than the next normal beat would be expected, and the QRS complex is wide and abnormal in morphology. A VE's does not have a preceding P wave.
In short, they look quite bizarre and are usually followed by a compensatory pause.

The timing of the VE's (relative to the sinus beat) may be fixed or variable.

Most VE's are benign, and often a normal variant, even in young healthy people. They do become more common with increasing age.

Despite their frequently benign nature, however, there are several things to watch out for:

  • If the VE's occur early in the cycle, they are sometimes superimposed on top of the T wave. This is known as 'R on T' and should be looked for, as this can trigger more sinister arrhythmias such as Ventricular tachycardia (VT) or ventricular Fibrillation (VF).
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  • Multiple, very frequent VE's, can be an indicator of underlying ischaemic disease. Any exertional history should be actively sought. If any uncertainty remains, exercise testing could be carried out. VE's which are abundant at rest, but go with exercise and return in recovery phase, are indicative of benign origin, and reassurance can be given. No treatment is necessary.
  • VE's which only appear - or get much worse - on exercise, are a bigger concern. Further investigations of cardiac function should be considered. 

Management of VE's

On the whole, the management of benign VE's is entirely symptomatic. If patients are not too troubled by them, and are happy with reassurance, then this may be all that is necessary.   

Investigations to consider at Primary Care level (not necessary in all cases) are:

  • U&E's, 
  • 24hr ECG
  • Exercise ECG

Patients who are troubled by the unpleasant frequency of their symptoms may benefit from beta-blockers. In severe cases, radio-frequency ablation can be considered. However, there is no evidence that suppression of VE's has any prognostic benefit.

As mentioned above, chronic frequent VE's which are multifocal, R on T, exertional, or occur in salvos, are associated with increased cardiovascular mortality and may warrant further investigation by a cardiologist.

Some common terminology and  definitions relating to VE's

When describing VE's, try and make reference to the following aspects:

Coupling Interval - this is the distance (time in seconds) between the VE and the previous sinus beat (QRS complex). Make mention of whether this is fixed (constant) or variable. 

Unifocal VE's all have the same morphology as each other, and all appear at the same point in the QRS cycle, with the same coupling interval.
image courtesy of

Multifocal VE's all look different from each other on the same ECG. They occur at different intervals, at various times in the QRS cycle, with different coupling intervals.
Image courtesy

Interpolated Beat - Most VE's are followed by a compensatory pause, with a delay to the next sinus beat. If there is no delay, however, then the VE is snuggly sandwiched between two normal sinus beats, with no interruption of the sinus rate. This VE is known as an 'interpolated' beat.

Image courtesy of
Image courtesy of

Bigeminy - Every other complex is a VE. i.e. Sinus beats and VE's alternate.

Trigeminy - Every third complex is a VE, with two normal sinus beats between every VE.

Couplet - Two VE's in succession, without a sinus beat between
Image courtesy of

Salvo - More than two ectopic beats in succession (ie a run a 3 to 6 VE's) is called a Salvo. (Three in a row may be referred to as a triplet or a Salvo).  If the duration is < 30 seconds, then this is also called 'self terminating ventricular tachycardia' 
Image courtesy of

Despite their slightly more worrying appearances, Bigeminy, Trigeminy, Couplets, and even salvos, can still be entirely benign - especially if they improve on exercise.

So, now how impressive are your notes or referral letters going to sound? ;)

Thank you. 

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