Case Report: Bigeminy with Alternating Injury Pattern Morphologies in a Young Woman After Cardiac Arrest

Coronary artery disease is uncommon in adults under the age of 35, and studies show a lower incidence in women of this age group. Physicians should suspect myocardial infarction in all patients who present with cardiac arrest and a shockable rhythm.

We report a case of a 34-year-old female who presented after return of spontaneous circulation following both pulseless electrical activity and ventricular fibrillation. The initial emergency department 12-lead electrocardiogram (ECG) demonstrated ST-segment elevation in the anterior precordial leads. The second, more notable, ECG showed a unique ischemic pattern of ventricular bigeminy with each beat containing a different morphology of injury pattern. Emergent cardiac catheterization found a 100% occlusion of the proximal left anterior descending artery.

Premature ventricular (or junctional) contractions can indicate ischemia when the morphology consists of excessive discordance between the QRS complex and the ST segment and T wave. This case illustrates the importance of scrutinizing each beat in every lead to increase sensitivity for ischemia.