Premature Ventricular Complexes

Harbinger of Cardiac Death or Benign Phenomena?

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Among the many different types of cardiac arrhythmias, few have created as much consternation and confusion among both doctors and patients as premature ventricular complexes (PVCs, also called premature ventricular contractions). In various doctors' offices, and at various points in history, PVCs have been regarded as either a harbinger of impending death or as completely benign phenomena that require no attention whatsoever.

The right answer is somewhere in between these two extremes. To really understand the significance of PVCs, we need to review what they are, what they imply in terms of medical prognosis, how they ought to be evaluated, and how they ought to be treated.

Premature Ventricular Complexes Diagnosis
Verywell / Cindy Chung

Symptoms

Most people with PVCs have no symptoms at all. They simply don't feel them. However, a substantial minority of people with PVCs will perceive palpitations—an unusual awareness of the heartbeat. These palpitations are often described as "skipped beats" or a "pounding heart." In some people, these symptoms can be difficult to tolerate.

Whether or not you perceive symptoms from your PVCs is related to many factors. Some people are just naturally more sensitive to any unusual events that occur in their internal organs, including PVCs.

Others are blissfully unaware of their PVCs during the day when they are active and distracted, but suddenly begin to feel them when they retire for the night and external stimuli are removed. But fortunately, most people with PVCs do not feel them at all.

PVCs are relatively common. In fact, up to 80% of people without heart disease will have at least one PVC during a 24 hour Holter monitor study. Those who have more than three PVCs in a row are said to have non-sustained ventricular tachycardia (NSVT).

Medical Significance of PVCs

PVCs have medical significance aside from the fact that they can produce symptoms. Over the years, the chief concern about PVCs is the idea that they may increase a person's risk for sudden death from cardiac arrest.

For decades, it was believed that the presence of PVCs significantly elevated that risk. More recent evidence has suggested that PVCs themselves may not increase the risk of sudden death very much (if at all) and that the association between PVCs and sudden death may be an indirect one.

Research suggests that people with frequent PVCs are more likely to have or develop significant heart disease.  However, while PVCs may be associated with increased cardiac risk, in most cases they are probably not the cause of the increased risk.

Cause of PVCs

A PVC is an extra electrical impulse arising from one of the cardiac ventricles. Because this extra impulse appears early (that is, before the next normal heartbeat has a chance to occur), it is called "premature."

The causes of PVCs aren't always clear. Certain triggers (like antihistamines, tobacco, anxiety, or exercise) can cause momentary palpitations. While caffeine is often invoked as a cause of PVCs, recent studies have failed to show that PVCs are produced by caffeinated products.  Similarly, an injury to the heart can make the cells of the ventricles electrically unstable.

Diagnosis

To reiterate, the chief medical significance of PVCs is that they may be associated with an increased risk of heart disease. So if you have PVCs, your doctor may want to perform a cardiac evaluation, looking for previously unknown heart disease, and assessing your risk of developing heart disease in the future.

The heart diseases commonly associated with PVCs include coronary artery disease (CAD) and heart failure due to dilated cardiomyopathy. PVCs are also frequently seen with hypertrophic cardiomyopathy and heart valve disease.

In general, an echocardiogram is a good way to screen for most of these cardiac conditions, although your doctor may also want to perform a stress thallium test to check more rigorously for CAD.

In addition, you and your doctor should go through a formal risk assessment including evaluating your diet, weight, smoking history, exercise habits, cholesterol and triglyceride levels, blood pressure, and blood glucose evaluation.

There is now evidence that if PVCs are persistently very frequent (consisting of 20% or more of heart beats), they can sometimes lead to PVC-induced cardiomyopathy. This means that people with very frequent PVCs should be strongly considered for treatment, according to latest ACC/AHA ventricular arrhythmia guidelines.

Treatment

Treating PVCs is not a straightforward matter given that their clinical significance can vary from one person to the next. Even among people with symptomatic PVCs, their very presence is not inherently indicative or predictive of anything.

The bulk of evidence today suggests that PVCs usually aren't inherently dangerous. In fact, studies have shown that suppressing PVCs with antiarrhythmic drugs may actually increase the risk of death.

That doesn't mean that PVCs are to be ignored, especially if the PVCs are interfering the normal function of the heart, or are causing significant symptoms. In such cases, a beta blocker or calcium channel blocker may be effective in reducing symptoms adequately. 

If beta blockers and calcium channel blockers are ineffective, antiarrhythmic drugs, especially Tambocor (flecainide), Rhythmol (propafenone), or Pacerone (amiodarone), can be quite effective in getting rid of PVCs. However, Tambocor and Rhythmol should be avoided in anyone with underlying heart disease, as they increase mortality in these people. And Pacerone is uniquely prone to cause disturbing or dangerous side effects, and is should be used very reluctantly for any non-life-threatening arrhythmia. 

Radiofrequency ablation, a specialized form of cardiac catheterization, can be effective in eliminating or greatly reducing PVCs in people who are having severe symptoms from this arrhythmia. This procedure should be considered as an option in cases where getting rid of the PVCs is deemed to be important, and where the only other option would be using potentially dangerous antiarrhythmic drugs. 

Treatment Considerations

Treatment would generally be indicated if it achieves two foundational aims:

  • First and foremost to reduce the risk of developing cardiovascular disease, including the risk of sudden death
  • Secondly, to reduce any symptoms of PVCs that may be interfering with a person's ability to function

These are two entirely different goals, and as doctors and patients make decisions about treating PVCs, each of these treatment goals needs to be addressed independently. 

A Word From Verywell

PVCs are very common, even among people who are perfectly healthy. Still, PVCs may cause symptoms, and they may indicate that some form of undiagnosed heart disease is present. So, finding PVCs should, at the very least, trigger a broader cardiac evaluation.

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