an 87 years old woman with a history of pd for the last 18 years , treated with l - dopa and dopamine receptor antagonists , presented with  off she was treated with carbidopa 87.5 mg / day , levodopa 875 mg / day , pramipexol 1.4 mg / day and mitrazapine 7.5 mg / day . there was no other medical history recorded , despite the advanced age of the patient , and the standard electrocardiogram ( ecg ) ( figure 1 ) at her admission was at normal range . full blood tests , including liver and renal function and electrolytes levels , were conducted and no abnormal values were detected . the previous medical therapy was discontinued 48 hours before the initiation of apomorphine , according to the usual practice . the patient was haemodynamically stable before the initiation of apomorphine and the heart rate and blood pressure was repeatedly monitored . ten minutes after the first subcutaneous administration of 10 mg of apomorphine , a heart rhythm disturbance was observed and recorded in a 12-lead ecg . the disturbance was ventricular bigeminy ( figure 2 ) , with a left bundle branch block morphology of the ventricular origin qrs complexes and a frontal qrs axis at 10. no haemodynamic instability was recorded and no symptom ( dizziness , palpitations , pre - syncope or syncope ) was reported by the patient . the next day the 12-lead ecg showed ventricular bigeminy again , so we decided to monitor the patients heart rhythm with a 24-hour ambulatory recorder ( holter ) . the recording showed brief periods of ventricular bigeminy ( figure 3 ) and no other arrhythmias . we conducted a two dimensional echo - cardiogram without any pathological findings that could pre - dispose to the emergence of a ventricular arrhythmia ( e.g. , ventricular hypertrophy or any indication of ischemic heart disease ) , and three days later we repeated the 24-hour ambulatory recording , which revealed no heart rhythm disturbances at all . the patient returned to the previous treatment for pd as it is mentioned above , and no such arrhythmia was recorded in the follow up visits of the patient . this was a rare case of heart rhythm disturbance associated with apomorphine treatment for pd.7 we conducted a review of related literature in pubmed and medline and no such case was ever reported . the available drug information does not mention such an arrhythmia as a possible adverse event related to the drug administration . the qt interval prolongation is the only electrocardiographic disturbance previously referred,8 but in our patient no change in qt interval was observed . the advanced age of the patient might be a predisposing factor to cardiac arrhythmias,9 although there was no previous history or symptoms of cardiac disease reported nor any structural abnormality detected . apomorphine is a potent dopamine receptor agonist , and it is known that other agonists like dopamine may increase the purkinje fibers automaticity and have a biphasic effect on action - potential duration causing atrial and ventricular tachyarrhythmias.10 yet , there is no evidence that such a mechanism is responsible for the reported incident of bigeminy . besides , the affinity of apomorphine to the 1 adrenergic receptors through which dopamine exerts its cardiac effects is very low.11 although the arrhythmia was self terminated and did nt cause any symptoms or haemodynamic instability , it would be reasonable to monitor inpatients closely for the emergence of cardiac dysrythmias at the initiation of the treatment with apomorphine and during dose titration . as far as outpatients are concerned ,
apomorphine is a well established treatment for the management of sudden , unexpected and refractory levodopa - induced  off 
 states in fluctuating parkinson s disease either as bolus injections or as continuous infusions . 
 incidents of atrial fibrillation associated with the administration of the drug have been reported in the past but no incidents of ventricular arrhythmias . 
 we report a case of ventricular bigeminy recorded in a female patient after the administration of apomorphine .