What are Premature Ventricular Complexes (PVCs)?

From the Guidelines

Premature ventricular complexes (PVCs) are extra heartbeats that originate from the ventricles, disrupting the normal heart rhythm and characterized by a wide QRS complex on an electrocardiogram (ECG), often benign but potentially associated with underlying cardiac disease or increased risk of mortality, especially if frequent or occurring in people with structural heart disease. PVCs are common, increasing in frequency with age, and may cause symptoms such as palpitations, skipped beats, or a fluttering sensation in the chest 1. In healthy individuals, isolated PVCs typically don't require treatment, but frequent PVCs (more than 10-15% of total heartbeats) or those occurring in people with structural heart disease may need medical attention 1.

Key Considerations

• PVCs are associated with increased cardiovascular risk and mortality, especially if frequent or multifocal 1
• The presence of PVCs on a 12-lead ECG or more than 30 PVCs per hour is associated with increased risk of ischemic heart disease events and mortality 1
• PVCs in patients with cardiovascular disease are common and have been associated with adverse outcomes, including increased risk of sudden cardiac death 1
• Treatment options for PVCs include lifestyle modifications, beta-blockers, calcium channel blockers, or antiarrhythmic medications like amiodarone, and catheter ablation may be recommended if medications fail to control symptoms 1

Diagnostic Evaluation

• A 12-lead ECG and exercise stress test are recommended for initial evaluation of PVCs 1
• An echocardiogram may be performed to rule out structural abnormalities, and other imaging studies such as computed tomography or magnetic resonance imaging may be considered in certain cases 1
• A 24-hour ambulatory monitor may be helpful in determining the frequency and pattern of PVCs, with more than 2000 PVCs per 24 hours associated with a higher likelihood of underlying cardiac disease 1

Management

• Lifestyle modifications, such as reducing caffeine, alcohol, and stress, are recommended as initial treatment for PVCs 1
• Beta-blockers, calcium channel blockers, or antiarrhythmic medications like amiodarone may be prescribed for symptomatic PVCs or those occurring in people with structural heart disease 1
• Catheter ablation may be recommended if medications fail to control symptoms or in cases of PVC-induced cardiomyopathy 1

From the Research

Definition and Prevalence of Premature Ventricular Complexes

• Premature ventricular complexes (PVCs) are relatively common, occurring in 3%-20% of the general population 2.
• PVCs are extremely common, found in the majority of individuals undergoing long-term ambulatory monitoring 3.
• They are usually considered benign but can be a sign of underlying cardiac disease and cause significantly impairing symptoms 2.

Causes and Mechanisms of Premature Ventricular Complexes

• The fundamental causes of PVCs remain largely unknown, but potential mechanisms include triggered activity, automaticity, and reentry 3.
• Increasing age, a taller height, a higher blood pressure, a history of heart disease, performance of less physical activity, and smoking each predict a greater PVC frequency 3.

Diagnosis and Evaluation of Premature Ventricular Complexes

• The history, physical examination, and 12-lead ECG are each critical to the diagnosis and evaluation of a PVC 3.
• An echocardiogram is indicated in the presence of symptoms or particularly frequent PVCs, and cardiac magnetic resonance imaging is helpful when the evaluation suggests the presence of associated structural heart disease 3.
• Ambulatory monitoring is required to assess PVC frequency 3.

Treatment and Management of Premature Ventricular Complexes

• Patients with no or mild symptoms, a low PVC burden, and normal ventricular function may be best served with simple reassurance 3.
• Either medical treatment or catheter ablation are considered first-line therapies in most patients with PVCs associated with symptoms or a reduced left ventricular ejection fraction 3.
• Catheter ablation is the most efficacious approach to eradicate PVCs but may confer increased upfront risks 3.
• Multicenter studies have shown a high success rate paired with a low complication rate with catheter ablation, and hence catheter ablation has emerged as the preferred therapeutic option for most patients with PVC-induced cardiomyopathy 4.

Complications and Risks Associated with Premature Ventricular Complexes

• High PVC burden may induce cardiomyopathy and left ventricular (LV) dysfunction or worsen underlying cardiomyopathy 5.
• PVCs in the presence of structural heart disease (SHD) may indicate increased risk of sudden death 5.
• Frequent PVCs can cause an often reversible form of cardiomyopathy, known as premature ventricular complex-induced cardiomyopathy (PIC) 4.
• PVCs may also trigger more malignant ventricular arrhythmias, particularly in patients with previous myocardial infarction 6.