From the Guidelines
The next step for a patient with 33% ventricular ectopies on a Holter monitor should be a comprehensive cardiac evaluation by a cardiologist to assess for underlying structural heart disease and potential cardiomyopathy. This high burden of ventricular ectopy (>20%) warrants further investigation as it may be associated with an increased risk of developing cardiomyopathy, as suggested by the 2017 European Heart Rhythm Association (EHRA) and ESC Council on Hypertension consensus document 1. The evaluation should include:
- An echocardiogram to assess for structural heart disease, left ventricular function, and signs of cardiomyopathy
- Additional testing may include exercise stress testing, cardiac MRI, and possibly electrophysiology studies depending on symptoms and initial findings
- Serological studies, including electrolyte levels, glucose, and thyroid studies may be used to assess reversible, secondary causes of increased ventricular ectopy, as recommended by the European Heart Journal consensus statements 1
- Identification of non-prescription or non-pharmacologic sources of increased adrenergic stimulation, including intake of alcohol, caffeine, and other stimulants including recreational drugs, should be documented in the history to provide appropriate counselling and/or help as needed.
If the patient is symptomatic or shows evidence of cardiomyopathy, treatment typically begins with beta-blockers such as metoprolol (25-100 mg twice daily) or calcium channel blockers like verapamil (120-360 mg daily in divided doses), as suggested by the 2018 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1. For patients with preserved cardiac function but a high ectopy burden, treatment may still be considered to prevent the development of cardiomyopathy. In cases where medication is ineffective or poorly tolerated, catheter ablation of the ventricular ectopic focus may be recommended, as suggested by the European Heart Journal consensus statements 1. Regular follow-up with serial echocardiograms every 6-12 months is important to monitor for the development of cardiomyopathy, especially if the high ectopy burden persists.
From the Research
Next Steps for Patient with 33% Ventricular Ectopies
- The patient's condition is considered significant, as studies have shown that frequent ventricular ectopy can lead to ectopy-mediated cardiomyopathy or ectopy-induced polymorphic ventricular arrhythmias 2.
- Given the high frequency of ventricular ectopies (33%), the patient may be at increased risk of developing heart failure and death, as suggested by a study that found a higher frequency of premature ventricular contractions (PVCs) to be associated with a decrease in left ventricular ejection fraction (LVEF), incident congestive heart failure (CHF), and mortality 3.
- Treatment options for the patient may include:
- Clinical surveillance to monitor the patient's condition and adjust treatment as needed.
- Medical therapy with anti-arrhythmic agents to reduce the burden of ventricular ectopies, although this may have side effects and may not eradicate the ectopy entirely 2.
- Catheter ablation, which is a potentially curative and safe option for most patients, especially those with ectopy-mediated cardiomyopathy or ectopy-induced polymorphic ventricular arrhythmias 2, 4.
- The choice of treatment will depend on various factors, including the patient's overall health, the severity of their condition, and their personal preferences.
- It is essential to note that ventricular ectopy is a common finding on Holter monitoring, and in some cases, it may be a benign finding, especially in patients with otherwise normal hearts 5.