Bigeminus R00.8

Bigeminy is a form of cardiac dysrhythmia in which each normal beat is followed over a longer period of time by an extrasystole with the same deformed ventricular complex. Bigeminus is a monotonic arrhythmia (Belz 2013). Each normal beat is followed by an ES: normal beat (N) - extrasystole (E) - NE - NE - NE (Herold 2022).

Bigeminal, along with other arrhythmias such as ventricular couplets, trigeminal, and triplets, belongs to the group of ventricular ectopy (Moon 2020). It can result from both supraventricular and ventricular extrasystoles (ES) (Sohns 2015).

• I. Atrial bigeminal:

Atrial bigeminal represents a special form of supraventricular extrasystole (SVES) (Haas 2011).

• II Ventricular Bigeminal:

These are complex ES that belong to grade III b in Lown's classification (Herold 2022), see also VES. Nowadays, however, the Lown classification is hardly used (Braun 2022).

Bigeminus can occur at any age - from fetal period to old age (Gravenhorst 2021).

- I. Atrial Bigeminus:

An atrial bigeminus is found almost exclusively in fetuses and neonates (Haas 2011).

- II. ventricular bigeminus:

Ventricular bigeminus occurs in approximately 17.2% of all patients with digitalis intoxication (Erdmann 1983).

In particular, the causes of bigeminy are:

- Digitalis intoxication

Digitalis intoxication is the most common cause. In addition to the bigeminal muscle, trigeminal muscle also occurs frequently (Herold 2022).

- Hypokalemia (Belz 2013).

Etiological causes of extrasystoles are also considered, which are:

- Physiological causes:

These are also found in healthy individuals. Here, extrasystoles occur due to increased sympathetic tone (Kasper 2015), emotional arousal, vegetative lability, overtiredness, ingestion of stimulants such as alcohol, nicotine, caffeine, increased vagotone, etc (Herold 2022).

- Organic diseases of the heart:

These include cardiomyopathies, myocarditis, coronary artery disease (Herold 2022), cardiac tumors, congenital heart defects (Paul 2018).

- Extracardiac Causes:

Extracardiac causes include hyperthyroidism, hypokalemia, use of certain medications such as antiarrhythmics, sympathomimetics, digitalis, tricyclic antidepressants (Herold 2022), catecholamines, quinidine, atropine. (Wolff 2012), fever, infections (van Aken 2007), acidosis, hypoxia, electrolyte disturbances, hypercalcemia, hypomagnesemia (Haas 2021).

- Idiopathic (Ip 2017)

- I. Supraventricular bigeminal:

Here, the SVES encounters ventricular tissue that is still refractory, thus ventricular excitation does not occur (Haas 2010).

- II. ventricular bigeminal:

In the extrasystole occurring on a normal beat, the time for sufficient diastolic blood filling of the heart is too short. Thus, no blood is ejected by this frustrated contraction. As a result, the peripheral pulse rate is usually halved. The slowing of the pulse and the reduced pumping capacity of the heart can lead to heart failure and cerebral ischemia (Belz 2013).

Symptoms typical of bigeminy often consist of a feeling of weakness and dizziness. These are caused by prolonged periods of bigeminy with a decrease in cardiac output (Braun 2022).

However, symptoms of extrasystoles may also occur such as:

- Cardiac syncope / presyncope (Kasper 2015).

- Palpitations (Herold 2022)

- Dyspnea (Meismann 2021)

Since extrasystoles cause an unconscious reaction of the autonomic nervous system, palpitations can trigger an anxiety reaction up to a panic attack in affected persons. These patients may complain of dyspnea, chest tightness, etc. (Meismann 2021).

In family practice, so-called "patient-activated event recorders = ER" can be used to diagnose arrhythmia or extrasystoles in patients with palpitations (Klein Wiele 2016).

Long-term ECG

- I. Supraventricular bigeminus:

Here, after the QRS complex of the normal beat, the ECG shows a premature onset of the P wave, which is not followed by a QRS complex (Haas 2011).

- II. ventricular bigeminus:

Typically, in this case, the P- wave is absent before each extrasystole. The ventricular complexes of the extrasystole are deformed like a leg block (Haas 2011) and widened to > 0.12 s (Kasper 2015).

In particular, check digitalis and potassium levels (Belz 2013).

In organic heart disease such as acute myocardial infarction, bigeminy may be a harbinger of life-threatening arrhythmias, including ventricular fibrillation. Also considered harbingers are:

- clustered polytopic and polymorphic VES

- couplets

- volleys

- R on T phenomenon (Herold 2022)

• I. Atrial bigeminal:

In atrial bigeminy, a special form of blocked supraventricular extrasystole, which occurs almost exclusively in fetuses and neonates, therapy is not necessary in the majority of cases, because the atrial bigeminy almost always disappears spontaneously (Haas 2011). A decrease in ventricular rate, which becomes hemodynamically significant, may eventually become problematic (Haas 2011).

• II Ventricular Bigeminus:

Therapy for ventricular bigeminy depends on the particular degree of circulatory insufficiency (Helfen 2020). If there is a decrease in cardiac output (stroke volume x number of beats per minute [Buchsteiner 2020]), antiarrhythmic drugs may be used. Therapy with drugs to increase the frequency may also be useful (Freytag 2010).

The primary antiarrhythmic drugs recommended are:

- Mexiletine, trade name Mexitil p. o. (Ullrich 2005)

or in case of digital overdose:

- Lidocaine i. v. 1.0 - 1.5 mg / kg bw (Helfen 2020).

- Digitalis overdose:

Magnesium sulfate or lidocaine should be administered in case of digitalis overdose. Dosage recommendation: magnesium sulfate 2 g i. v., lidocaine1.0 - 1.5 mg / kg bw i. v. (Help 2020).

- Digitalis intoxication:

- Immediate cessation of digitalis administration

- Promote elimination of digitalis by:

- Antidote treatment with Fab antibody fragments such as DigiFab (Böhm 2000). Dosage:

- if the amount of digitalis is known: 80 mg of antidigoxin- Fab binds 1 mg of digoxin, so that the digoxin- level decreases by 1ng / ml and for digitoxin by 10 ng / ml (Flake 2021).

- in case of unknown amount of digitalis after criminal or suicidal intent: bolus of 160 mg as a short infusion in 5% glucose over 20 min, then 20 mg / h over 12 h (Flake 2021)

- Detoxification measures in the form of:

- Gastric lavage at a time interval < 1 h.

- administration of activated charcoal

- in case of intoxication with digitoxin:

- additional use of exchange resins such as colestipol or colestyramine

- Hemoperfusion:

- however, does not work in case of intoxication with digoxin

- Hemodialysis and peritoneal dialysis are not suitable for glycoside elimination (Böhm 2000).

- Symptomatic therapy in the form of:

- temporary pacemaker

- Atropine for bradycardia (Herold 2022) Dosage: 1mg atropine i. v. (Böhm 2000)

- Balancing of electrolytes, especially hypokalemia:

- Hypokalemia is often associated with alkalosis. In this case, the administration of KCL is recommended. Dosage recommendation: KCL orally 50 - 100 mmol / d (Schoenenberger 2009).

- In metabolic acidosis: potassium administration as gluconate or citrate. Dosage recommendation: 60 - 240 mmol potassium / d (Schoenenberger 2009).

- In diuretic-induced hypokalemia: therapy with amiloride, spironolactone or KCL (Schoenenberger 2009). Dosage recommendations:

- Amiloride 5 - 40 mg / d

- Spironolactone 50 - 100 mg / d

- KCL 40 mmol / d (Schoenenberger 2009)

The prognosis of atrial bigeminy, a special form of blocked supraventricular extrasystole, is good (Haas 2011).

The prognosis of idiopathic ventricular extrasystoles is also good, provided there is no structural disease of the heart (Muser 2021) and no malignant potential develops (Ip 2017). For more details, see VES.

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