This ECG photograph is most consistent with:

The machine printout also appears to state “Ventricular contractions Bigeminy.”

PVC bigeminy can be benign, but it should not be dismissed without context. Common contributors include stimulants, stress, poor sleep, alcohol, electrolyte disturbance, thyroid disease, heart disease, and some medications. A clinician commonly confirms the pattern with a repeat ECG or Holter monitor and may check electrolytes, thyroid function, and an echocardiogram depending on symptoms and history. The ESC overview of ventricular extrasystoles describes bigeminy as a PVC following every normal beat.

Seek urgent medical assessment now if there is chest pain, fainting or near-fainting, severe breathlessness, persistent dizziness, a sustained fast heartbeat, or known heart disease. Otherwise, arrange a prompt review with a physician/cardiologist, especially if this is new or frequent.

Usually, metoprolol succinate should not be stopped suddenly, particularly if it has been taken regularly for more than a few days or if the patient has angina, coronary artery disease, prior heart attack, or heart failure.

Abrupt withdrawal can cause rebound sympathetic activity: rapid pulse, raised blood pressure, return or worsening of palpitations/angina, and rarely myocardial infarction. Product labeling advises reducing it gradually over about 1 to 2 weeks when possible. The official prescribing information specifically warns about abrupt cessation.

Exception: if the prescriber told the patient to stop immediately because of a serious problem such as very low pulse, fainting, marked low blood pressure, worsening heart block, severe wheeze, or an acute adverse effect, follow that prescriber’s explicit instruction and contact them promptly to confirm the plan.

For this patient with frequent PVCs/bigeminy, do not assume that stopping metoprolol is automatically appropriate. Metoprolol often suppresses palpitations/PVCs, though it may be stopped for another reason such as bradycardia or intolerance. Ask the prescribing clinician today for a specific tapering schedule based on the current dose, duration of treatment, reason it was prescribed, pulse, and blood pressure.

Seek urgent care if chest pain, fainting, severe shortness of breath, sustained fast heartbeat, or severe dizziness occurs.

The type of inhaler matters.

Because the treating doctor has specifically advised stopping the inhaler, do not continue or restart that exact inhaler on your own. But contact the doctor or clinic today to clarify:

This needs prompt clarification because metoprolol can also worsen bronchospasm in some people with asthma, while beta-agonist relievers can aggravate palpitations/PVCs. The balance has to be individualized.

Go for urgent assessment if there is worsening wheezing or breathlessness, inability to speak full sentences, blue lips, a reliever inhaler is needed repeatedly, chest pain, fainting, or severe persistent palpitations. The GINA asthma guidance also notes that high doses of beta-agonist relievers can cause palpitations, low potassium, and arrhythmias.

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