Bigeminy on Exertion MUHAMMAD ABDEL RAZZAK Circulation. 1963;28:32-34 doi: 10.1161/01.CIR.28.1.32 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 1963 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/28/1/32 Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/ Downloaded from http://circ.ahajournals.org/ by guest on September 9, 2014 Bigeminy on Exertion By MUHAMMAD ABDEL RAZZAK, M.D. BIGEMINY or coupling of beats may involve the atria alone, the ventricles, or both. There are many causes for coupling, the commonest and most important being extrasystoles.1 In extrasystolic bigeminy, there is a premature contraction after each normal beat. The premature beat may origimmate from the sinoatrial node, the atrium, the atrioventricular node, the atrioventricular bundle, or the venitriele. The last ventricular extrasystolic bigeminy, constitutes more than 80 per cent of cases. The premature contractions may arise from right or left ventriele, and very rarely may arise from the intervenitricular septum. Thev may originate from one or more foei.2 In ventricular extrasystolio bigeminy the atrial rhythm may be normal or abnormal. Atrial fibrillation is seen in nearly 40 per cenrt of cases; overdosage of digitalis is the main cause of coupling. The aim of the present study is to report the occurrence of v-enitricular extrasystolie bi:geminy on' exertioni. Material Case 1 A 40-year-old engineer reported irregular heart action on effort. Physical examination was within normal limits, and electrocardiography showed a normal tracing except for incoimiplete right bundle-branch block as evidenced by deep S waves in leads II and III, and an rsr' pattern in V1. The Master exercise test3 was performned and showed ventricular extrasystolic bigenminy, every normal beat being followed by a premature contraction. After 10 ininutes of bed rest, the bigeminy disappeared. One month later, the patient was seen again because of the same discomfort. Electrocardiography again revealed similar findings. One week later, bigeminv was not seen after exertion. Case 2 A 51-year-old clerk on routine physical examination showed no abnormality except occasional premature beats. Electrocardiogranms before and after the Master exercise test (fig. 1) showed coupling on exertion and returned to the previous status within 2 iiiinutes. At a second examination a few days later the electrocardiogranm was exactly the sanie as the previous record. The patient was instructed to omiiit cigarettes and coffee amid tea. After a week on this reginiei, exercise did not precipitate vemitricular preimature comitractions. Case 3 A 25-year-old woman with precordial discomiifort showed onlym-iultiple irregularly spaced extrasystoles due to multiple ummifocal premature beats (fig. 2A). On exercise this irregular rhythm changed to bigenminy (fig. 2B). After 10 days of rest and potassiumll citrate, extrasystoles were not seen at rest (fig. 2C), nor omi exertioii (g. 2D). Case 4 A 28-year-old carpenter was exaimined because of an irregular pulse. The thyroid gland was slightly enlarged, but there were no signs of hyperactivity. The pulse showed interniittent bigeminimy. Physical exanmination was otherwise negative. After a few m-linutes of exercise bigeniiny reappeared. An electrocardiogram showed ventricular extrasystolic bigemiiny., which gradually disappeared. Case 5 A 40-year-old man complained of a miissing FrIom the Medical Unit, Faculty of Medicine, Cairo Uniiversity, UInited Arab Republic. Figure 1 Lead V2 from an electrocardiogram of a 51-yearold clerk. Upper tracing, at rest; lower tracing, after the Master exercise test. 32 Circulation, Volume XXVIII, July 19639 Downloaded from http://circ.ahajournals.org/ by guest on September 9, 2014 33 BIGEMINY ON EXERTION zE 7;;7 iEi jE iE p V * V :: 0 -believe that premature ventricular contractions precipitated by exercise are usually related to coronary insufficiency.5 8 Others think that these extrasystoles are of little pathologic ie.9i 10 Sa db r " after his extensive study of the problem, suggests that the *. ~~~~~~~decisive factor is whether or not the rhythm disturbance is accompanied by ST and T depression. only abnormality in our subjects was ~~~~~~~~~The .B ~~~~bigeminy that appeared on exertion and disappeared on rest. The duration of rest re~~"<~ quired in our subjects varied. In all subjects coupling was of the extrasystolic venltricular type, and the premature beats originated from single focus.12 The atria showed normal ~~~~~~~~~~~a ~sinus rhythmi in all cases. These findings do iiESiLEL giEi; i. Figure 2 Lead II from electr ocardiographic tracings of a female patieent aged 25 years. A, at rest; B, af ter exercise; C, after treatment at bed rest; anzd D, after treatment on exertion. examnationFigureLead3 II from beatbea aa re-ulr Phscleaiton rglritras i-ntrvals.Physicl and electrocardiography revealed quadrigeminy, the fourth beat was a unifocal ventricular extrasystole (figf. 3A). On exercise the rhythm changed to bigemiiny, the added premnature beat arising, from the same focus (fig. 3B). The new premature beats disappeared on rest anid reappeared when exercise was resumed. Two simiilar cases are represented by two male subjects of the third decade; the tracings were recorded bef ore and af ter exercise. In the first (fig. 4) a ventricular premature beat regularly occurred after two normal cardiac contractions, i.e., tigeminy. In the other electrocardiogram (fig. 5) ventricular extrasystoles appeared following a group of three normal heart beats. After rest these premature beats disappeared, to appear again on exercise. Discussion The occurrence of ventricular premature beats after exercise has been observed by many workers since 1927. 1 Some authors 40-year-old B, on electrocardiographic records of a A, at rest, showing quadrigeminy; showing bigeminy. man. exertion, Figure 4 Lead 11 from electrocardiograms of a male subject. A, at rest; B, after exercise, showing trigeminy. Circulation, Volume XXVIII, July 1963 Downloaded from http://circ.ahajournals.org/ by guest on September 9, 2014 RAZZAK 34 Figure 5 Lead II from electrocatrdiograms of a man. Upper tracing, before exercise; lower tracing, after exercise, showing quadrigeminy. not agree with those of Parsonnet et al.,2 who reported that in ventricular extrasystolic bigeminy the multifocal slightly exceed those of unifocal origin. Nothing indicates coronary artery disease as a cause of these regularly occurring premature contractions after exercise in our subjects. They may be due to increase in excitability of the ventricular musculature that occurs in the myocardium oni exercise. 4. BOURNE, G.: An attempt at the clinical classification of premature ventricular beats. Quart. J. Med. 20: 219, 1927. 5. GOLDHAMER, S., AND SCHERF, D.: Elektrokadiographische Untersuchungen bei Kranken mit Angina Pectoris. Ztschr. Klin. Med. 122: 134, 1932. 6. PROGER, S. H., MINNICH, W. R., AND MAGENDANTZ, H.: The circulatory response to exercise in patients with angina pectoris. Therapeutic implications. Am. Heart J. 10: 511, 1935. 7. PORTER, W. B.: The probably grave significance Summary Regularly occurring ventricular extrasystoles taking the form of bigeminy, trigeminy, or quadrigeminy may appear on exertion in an apparently otherwise normal heart. of premature beats occurring in angina peetoris induced by effort. Am. J. M. Sc. 216: 509, 1948. MANN, R. H., AND BURCHELL, H. B.: Ventricular premature contractions and exercise. Proc. Staff Meet., Mayo Clin. 27: 383, 1952. MASTER, A. M., FIELD, L. E., AND DoNoSo, E.: Coronary artery disease and two-step exercise test. New York State J. Med. 57: 1051, 1957. LEPESCHKIN, E., AND SURAWICZ, B.: Characteristics of true-positive and false-positive results of electrocardiographic Master two-step exercise test. New England J. Med. 258: 511, 1958. SANDBERG, L.: Studies on the electrocardiographic changes during exercise tests. Acta med. scandinav., Suppl. 365, 1961. GOLDMAN, M. J.: Principles of Clinical Electrocardiography. Ed. 2. New York, Lange Medical Publications, 1958, p. 227. 8. 9. Acknowledgment I wish to record my thanks to Dr. A. Hassaballah for his help, without which this work would have been impossible. 1 0. References 1. FRIEDBERG, C. K.: Diseases of the Heart. Ed. 2. Philadelphia, W. B. Saunders, Co., 1956, p. 332. 2. PARSONNET, A. E., MILLER, R., BERNSTEIN, A., AND KLOSK, E.: Bigeminy. Am. Heart J. 31: 74, 1945. 3. MASTER, A. M.: A test for coronary insufficiency. Ann. Int. Med. 32: 862, 1950. 11. 12. Circulation, Volume XXVIII, July 1963 Downloaded from http://circ.ahajournals.org/ by guest on September 9, 2014