Non-conducted PAC's in Bigeminy

Image 1- ECG case

Came in due to fall. Do you think this patient needs a pacemaker?





What is the cause of the sudden bradycardia?

Image 2- ECG Case with PAC's labeled

If you look at V1, the T wave after the 3rd QRS complex is distorted ( a bit "pointee"). Then seemingly a missing beat. The T waves of the next complexes are distorted. Those are the P waves that appeared so early or they are premature atrial complexes (PAC) and are non-conducted because the AV node is refractory.

This is a very nice example of a Mobitz II mimic. This is non-conducted PAC in bigeminy.

For the case, the patient was asymptomatic during the event and the fall was determined to be mechanical. The event did not recur and the patient was discharged after a few days.