Differential Diagnosis

Multifocal atrial tachycardia (MAT)

Wolff-Parkinson-White (WPW)

Inferior ischemia

Multiple premature ventricular contractions (PVCs)

First-degree AV block

The patient is experiencing multiple premature ventricular contractions (PVCs). The ECG reveals wide complex, intermittent, beats consistent with premature ventricular contractions.

The normal PR interval is 120-200 ms; in this ECG it is 161ms, so there is not a first-degree AV block. The underlying rhythm is a regular sinus rhythm, so MAT is not occurring. The inferior leads are II, III, and aVF, but they do not demonstrate ischemic changes such as T wave inversion or ST segment changes; the patient does not have inferior ischemia. WPW is characterized by a short PR interval and a delta wave, neither are present in this ECG.

Learnings/What to Look for

  • A PVC is a wide complex beat, originating in the ventricle
  • Patients with palpitations commonly have an ECG tracing performed, but it is difficult to correlate the presence of PVCs with palpitations, as many patients have asymptomatic PVCs
  • If the history is not suggestive of ischemia or an electrolyte abnormality, no further evaluation is necessary for PVCs

Pearls for Urgent Care Management and Considerations for Transfer

  • Compare to a previous ECG, if available
  • Correlate the presence of PVCs with the patient’s symptoms (if they are placed on a monitor). If there is suspicion of an electrolyte abnormality based on medications or GI losses (vomiting or diarrhea), then blood work can be considered. For isolated PVCs, no further evaluation is necessary
  • Multiple PVCs occurring back to back may be from intermittent ventricular tachycardia (VT)—if a patient is symptomatic or having “runs” of VT, then emergent transfer to an ED is indicated
A 42-Year-Old Man with a ‘Flipping’ Sensation in his Heart
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