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Premature Ventricular Contraction

Ventricular Extrasystoles

A premature ventricular contraction is defined as an early ventricular depolarization that is quite commonly encountered in the general population. It is considered to be a benign finding in otherwise healthy patients without structural heart disease (SHD) of any kind, but many studies have pointed out its role in the development of many cardiovascular diseases, including myocardial infarction and stroke. The diagnosis is made after a comprehensive cardiac workup.


Presentation

A premature ventricular contraction (PVC) is often regarded as a benign incidental finding, and its exact pathogenesis remains to be confirmed. It is known that PVCs arise as a result of increased automaticity (predominantly from the right ventricular outflow tract) presumably due to the effects of catecholamines, electrolyte imbalance, physical activity, cardiotoxic effects, ischemia and reperfusion changes, and menstrual cycles [1] [2]. It has been reported that between 40-75% of the population exhibited PVCs on routine 24h or 48h Holter monitoring, and its frequency is significantly linked to advancing age [1] [3]. Its association with ventricular dysfunction, cardiomyopathy, ischemic stroke, sudden cardiac death, and various other cardiovascular risks, however, particularly on the grounds of a pre-existing structural heart disease (SHD), has been extensively evaluated [1] [3] [4] [5] [6]. For this reason, its early recognition and monitoring may be of clinical importance. Signs and symptoms are nonspecific and range from mild to severely debilitating. Palpitations, presyncope, syncope and complaints of chest pain in otherwise healthy individuals with no apparent cardiac disease are the main features [1] [7]. Moreover, heart failure and cardiomyopathy can also develop, presumably due to impaired ventricular dysfunction and consequent reductions in cardiac output [1] [7].

Weight Loss
  • Ask specifically about any supplements taken to help with weight loss or increase energy levels. Almost all of them contain caffeine or other “natural” sympathomimetic agents. Also ask specifically about illicit drug use.[doi.org]
  • loss supplements may aggravate premature ventricular contractions and should never be used without consulting with one's physician); stop drug abuse such as amphetamines, cocaine; and stop cigarette smoking.[medicinenet.com]
  • For relief of palpitations, one may consider the following measures: stop alcohol and caffeine intake; stop over-the-counter nasal decongestants that may contain adrenaline such as medications containing pseudoephedrine (certain weight loss supplements[studynursing.blogspot.com]
Increased Energy
  • Ask specifically about any supplements taken to help with weight loss or increase energy levels. Almost all of them contain caffeine or other “natural” sympathomimetic agents. Also ask specifically about illicit drug use.[doi.org]
Movement Disorder
Rales
  • […] underlying heart or vascular disease, eg: Significant murmurs Abnormal S3 or S4 Displaced and diffuse point of maximal impulse or precordial heave Signs of right or left heart failure, or both, eg, peripheral edema, elevation of jugular venous pulse, rales[doi.org]
Regurgitation
  • Abstract Cryoablation in the left ventricular outflow tract and aortic valve replacement were conducted in a 70-year-old man with frequent premature ventricular contraction and nonsustained ventricular tachycardia complicated by Sellers grade 4 aortic regurgitation[ncbi.nlm.nih.gov]
  • […] in assessing the changes of the myocardium in PVC and other similar rhythm disorders, and most common findings are cardiomyopathies (in fact, the reversible form of PVC-related cardiomyopathy is described in literature), valvular disease (eg. mitral regurgitation[symptoma.com]
  • I have trace amount of regurgitation in my mitral and aortic valve. I also have an abnormal EKG. Inverted t waves as well as elevated waves. I get the PVC/APCs at rest and as of late during exercise.[medhelp.org]
Skipped Beats
  • These extra beats disrupt your regular heart rhythm, sometimes causing you to feel a fluttering or a skipped beat in your chest. Premature ventricular contractions are common — they occur in many people.[mayoclinic.org]
  • The extra beat is followed by a stronger heartbeat, which creates the feeling of a skipped beat or a flutter. These extra beats are usually less effective in pumping blood throughout the body.[umcvc.org]
  • A PVC may be perceived as a “skipped beat” or felt as palpitations in the chest.[ncheartvascular.com]
Left Ventricular Dysfunction
  • Second, left ventricular dysfunction has a stronger association with increased mortality rate than do PVCs. Many now believe that PVCs reflect the severity of heart disease rather than contribute to arrhythmogenesis.[emedicine.com]
  • However, IC-AADs increase mortality in patients with PVCs and left ventricular dysfunction after myocardial infarction.[ncbi.nlm.nih.gov]
  • ventricular dysfunction and reduced contractility, as well as increased dimensions of the left ventricle.[symptoma.com]
Ventricular Bigeminy
  • ECG Examples: Premature Ventricular Contraction (PVC) ECG (Example 1) Premature Ventricular Contraction (PVC) ECG (Example 2) Premature Ventricular Contraction (PVC) ECG (Example 3) Ventricular Bigeminy ECG (Example 1) Ventricular Bigeminy ECG (Example[healio.com]
  • Voltage maps were acquired at baseline and after 14 weeks of ventricular bigeminy. RESULTS: In the PVC group, left ventricular ejection fraction decreased from 67% 7% to 44% 15% (P .05) with no change in controls (71% 6% to 73% 4%; P .56).[ncbi.nlm.nih.gov]
  • ECG Basics: Sinus Rhythm With Ventricular Bigeminy This rhythm strip offers two leads taken at the same time, Lead II and Lead V1. The Lead II strip may not look "typical" to a beginning student, because the sinus beats are very small and biphasic.[ecgguru.com]
  • Shanmugam N et al . (2006) 'Frequent' ventricular bigeminy—a reversible cause of dilated cardiomyopathy. How frequent is 'frequent' . Eur J Heart Fail 8 : 869–873 7.[nature.com]
Irregular Heart Rhythm
  • Ventricular Arrhythmias Premature ventricular contractions (PVCs) are the most common cause of irregular heart rhythms.[my.clevelandclinic.org]
  • They're the most common reason for arrhythmia , or an irregular heart rhythm.[webmd.com]
  • The physical examination findings are often normal except irregular heart rhythm when PVCs are frequent.[circep.ahajournals.org]
Ventricular Trigeminy
  • Trigeminy ECG (Example 1) Ventricular Trigeminy ECG (Example 2) Ventricular Trigeminy ECG (Example 3) References: 1.[healio.com]
  • If it occurs after every second normal beat, it is called ventricular trigeminy and if it occurs after every third beat, it is called ventricular quadrigeminy. If more than three PVCs occur in a row, it can be identified as ventricular tachycardia.[cardiorhythm.co.za]
Emotional Lability
  • A 17-year-old female diagnosed with bipolar II disorder was treated for emotional lability with quetiapine.[ncbi.nlm.nih.gov]

Workup

Given the fact that a nonspecific clinical presentation is seen in patients with PVCs, a detailed clinical and laboratory workup should be conducted. Firstly, a complete patient history including the onset, progression and duration of symptoms, evaluation of preexisting cardiovascular risks and comorbidities, and a thorough family history is performed [1] [5]. Physical examination may be apparently normal apart from detection of arrhythmia on cardiac auscultation [7]. Still, syncope and associated symptoms, particularly if an arrhythmia is noted during the exam, are sufficient to raise clinical suspicion of a cardiac pathology [1] [5], in which case several laboratory studies are necessary. A standard 12-lead electrocardiography (ECG), widely recognized for its ability to determine the exact type of arrhythmia and its origin, is performed first, but because PVCs are often not caught during this short testing period, 24-hour or 48-hour Holter monitoring is recommended [1]. In fact, studies advocate the use of repeating the 24-hour or even 72-hour monitoring in order to ensure PVCs are not missed [1] [7]. Echocardiography is the cornerstone in assessing the changes of the myocardium in PVC and other similar rhythm disorders, and most common findings are cardiomyopathies (in fact, the reversible form of PVC-related cardiomyopathy is described in literature), valvular disease (eg. mitral regurgitation), left ventricular dysfunction and reduced contractility, as well as increased dimensions of the left ventricle [1] [7]. Cardiac magnetic resonance imaging has also been mentioned as a possible method in confirming the diagnosis [1].

Ejection Fraction Decreased
  • RESULTS: In the PVC group, left ventricular ejection fraction decreased from 67% 7% to 44% 15% (P .05) with no change in controls (71% 6% to 73% 4%; P .56).[ncbi.nlm.nih.gov]
Wide QRS Complex
  • Wide complexes; because they come from the ventricles and do not use the normal ventricular conduction system, action potentials need to travel from myocyte to myocyte, which is much slower, creating a wide QRS complex.[healio.com]
  • A premature ventricular complex is recognized on the ECG as an abnormal and wide QRS complex occurring earlier than expected in the cardiac cycle.[ecgwaves.com]
  • Mont L. et al: A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation 83:1649, 1991. ‎[books.google.de]
  • If P Waves are present and occur independently of the QRS complexes, the P-R intervals will vary widely. QRS complexes are described as “wild-looking” and with great swings and exceed 0.12 second.[nurseslearning.com]
Ventricular Bigeminy
  • ECG Examples: Premature Ventricular Contraction (PVC) ECG (Example 1) Premature Ventricular Contraction (PVC) ECG (Example 2) Premature Ventricular Contraction (PVC) ECG (Example 3) Ventricular Bigeminy ECG (Example 1) Ventricular Bigeminy ECG (Example[healio.com]
  • Voltage maps were acquired at baseline and after 14 weeks of ventricular bigeminy. RESULTS: In the PVC group, left ventricular ejection fraction decreased from 67% 7% to 44% 15% (P .05) with no change in controls (71% 6% to 73% 4%; P .56).[ncbi.nlm.nih.gov]
  • ECG Basics: Sinus Rhythm With Ventricular Bigeminy This rhythm strip offers two leads taken at the same time, Lead II and Lead V1. The Lead II strip may not look "typical" to a beginning student, because the sinus beats are very small and biphasic.[ecgguru.com]
  • Shanmugam N et al . (2006) 'Frequent' ventricular bigeminy—a reversible cause of dilated cardiomyopathy. How frequent is 'frequent' . Eur J Heart Fail 8 : 869–873 7.[nature.com]
Early Repolarization
  • Long-term outcome associated with early repolarization on electrocardiography. N Engl J Med. 2009 ; 361 :2529–2537. Crossref Medline Google Scholar 49. Bhushan M, Asirvatham SJ.[circep.ahajournals.org]

Treatment

  • Treatment For most people, PVCs with an otherwise normal heart won't need treatment. However, if you have frequent PVCs, your doctor might recommend treatment.[mayoclinic.org]
  • In addition, catheter ablation has emerged as an effective treatment modality that has compared favorably to pharmacological antiarrhythmic therapy.[ncbi.nlm.nih.gov]
  • Patients' symptoms were calculated before and after treatment. The number after treatment was subtracted from the number before treatment. That was then divided by the number before treatment, and the result was multiplied by 100.[townsendletter.com]

Prognosis

  • Although the prognosis in patients with frequent PVCs was considered relatively benign, attention should be paid to the progression of the LV dysfunction during a long-term observation, especially in patients with a high PVC prevalence.[ncbi.nlm.nih.gov]
  • To precisely discuss the long-term prognosis, a longer observation period with a larger number of patients would be necessary.[doi.org]
  • Presence of heart disease should be sought and, if absent, indicates good prognosis in patients with PVCs.[escardio.org]

Etiology

  • […] latest insights into the treatment of ventricular tachyarrhythmia, especially with the advent of catheter ablation, there has been renewed interest in premature ventricular contractions, not only as a predictor of arrhythmia, but also for their potential etiological[ncbi.nlm.nih.gov]
  • […] focus, which occurs before the usual sinuatrial beat, characterized by premature, widened, bizarre QRS complexes, not preceded by a P wave; PVCs are extremely common, occur in 1 2 of normal adults monitored by EKG for 24 hrs, and are of no significance Etiology[medical-dictionary.thefreedictionary.com]
  • Etiology Although in a great majority of patients, PVCs are not a sign of an underlying heart disease, following conditions can trigger PVCs in some people: Hematologic disease Acute MI or angina Hypertrophic or dilated cardiomyopathy Myocarditis Mitral[xpertdox.com]
  • LBBB is an indicator of cardiac disease, but not specific to one etiology.[ecgguru.com]
  • Etiology Causes of PVCs include: · ischemia · certain medicines such as Digoxin, which increases heart contraction · myocarditis · cardiomyopathy, hypertrophic or dilated · myocardial contusion · myocardial infarction · hypoxia · hypercapnia (CO2 poisoning[townsendletter.com]

Epidemiology

  • Epidemiology. 1992 ; 3 : 434–440.[doi.org]
  • Some epidemiological data exist with an association between PVCs activity with caffeine intake, but experimental human studies have not produced consistent results to establish this link.[escardio.org]
  • Relationship of premature systoles to coronary heart disease and sudden death in the Tecumseh epidemiologic study. Ann Intern Med. 1969; 70 :1159–66. [ PubMed ] 22. Bikkina M, Larson MG, Levy D.[ncbi.nlm.nih.gov]
  • Methods Statistics Trigonometry Medical & Nursing Anatomy Anesthesiology Audiology Bacteriology Biochemistry Bioethics Biomedical Science Cardiology Cardiovascular Childbirth Chiropractic Dentistry Dermatology Diagnostic Imaging Drugs Endocrinology Epidemiology[brainscape.com]
Sex distribution
Age distribution

Pathophysiology

  • This title features pathophysiology content that serves as a bridge between normal function and disease, and Read more... Reviews User-contributed reviews[worldcat.org]
  • It is not intended to be a comprehensive review of the pathophysiology, electrophysiology, or localization and ablation of PVCs. We will discuss approaches to the initial therapy of symptomatic PVCs.[doi.org]
  • Pathophysiology of physiologic cardiac pacing: advantages of leaving well enough alone. JAMA. 2002 ; 288 :3159–3161. Crossref Medline Google Scholar 40. Goldberger JJ, Kadish AH. Cardiac memory. Pacing Clin Electrophysiol. 1999 ; 22 :1672–1679.[circep.ahajournals.org]
  • Pathophysiology of PVCs In PVCs, ventricular myocytes spontaneously depolarize to create an extra systole that creates mechanical dyssynchrony with the cardiac cycle. 2,3 Affected cells are triggered by cyclic adenosine monophosphate-mediated and calcium-dependent[thecardiologyadvisor.com]

Prevention

  • Ablation of the triggering PVCs may eliminate the fatal arrhythmias and prevent the sudden death in patients with LQTS.[ncbi.nlm.nih.gov]
  • Some people may take medicine to prevent these heartbeats and to relieve symptoms. If you have a known heart problem, such as heart failure or heart disease, PVCs may be a sign that a dangerous heart rhythm could occur.[uwhealth.org]
  • Drug treatment is aimed at suppressing premature ventricular contractions (PVCs) in order to prevent serious ventricular arrhythmias and to reduce the risk of sudden death.[healthcentral.com]

References

Article

  1. Sheldon SH, Gard JJ, Asirvatham SJ. Premature Ventricular Contractions and Non-sustained Ventricular Tachycardia: Association with Sudden Cardiac Death, Risk Stratification, and Management Strategies. Indian Pacing Electrophysiol J. 2010;10(8):357-371.
  2. Noheria A, Deshmukh A, Asirvatham SJ. Ablating Premature Ventricular Complexes: Justification, Techniques, and Outcomes. Methodist Debakey Cardiovasc J. 2015;11(2):109-120.
  3. Saurav A, Smer A, Abuzaid A, Bansal O, Abuissa H. Premature ventricular contraction-induced cardiomyopathy. Clin Cardiol. 2015;38(4):251-258.
  4. Eugenio PL. Frequent Premature Ventricular Contractions: An Electrical Link to Cardiomyopathy. Cardiol Rev. 2015;23(4):168-172.
  5. Giles K, Green MS. Workup and management of patients with frequent premature ventricular contractions. Can J Cardiol. 2013;29(11):1512-1515.
  6. Ofoma U, He F, Shaffer ML, Naccarelli GV, Liao D. J Am Heart Assoc. 2012;1(5):e002519.
  7. Lee GK, Klarich KW, Grogan M, Cha YM. Premature ventricular contraction-induced cardiomyopathy: a treatable condition. Circ Arrhythm Electrophysiol. 2012;5(1):229-236.

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Last updated: 2019-06-28 09:29