Mixed Bigeminy
Report:
Sinus rhythm 74/min
SVEBs, blocked
VEBs
Left ventricular hypertrophy with ST/T changes
Comment:
The diagnosis of sinus bradycardia is refuted by the negative (in the inferior leads) P waves â probably of junctional origin â after the first, fifth and sixth sinus beat. Marriottâs âcommonest causes of pausesâ135 follow the preceding QRSs by approximately 0.52â.
From the third sinus beat onward the rhythm is, in a sense, bigeminal: at first with the two VEBs and then with blocked SVEBs. The pulse would, most likely, reveal only a regular bradycardia 37/min.
In V1, the broad complex takes almost 0.08â to descend to its nadir: this makes a ventricular origin more likely than a supraventricular one, with LBBB aberrancy.
If the junctional extrasystoles were blocked retrogradely as well, the only evidence of their existence would be unexplained blocked P waves â a pseudoblock. Unfortunately, no examples could be found in this patientâs record. In the company of VEBs, the junctional SVEBs may well be main-stem (bundle of His) extrasystoles, with antegrade block. Standard ECG cannot tell them apart.
187. 71 year old man with history of myocardial infarction 20 years previously, presenting with angina and light-headedness.
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