What is the significance of a sinus rhythm with frequent premature ventricular contractions (PVCs) and ventricular trigeminy?

From the Guidelines

For patients with sinus rhythm and frequent PVCs, including those with ventricular trigeminy, the primary approach should focus on managing symptoms and addressing underlying heart health, with beta-blockers being a first-line treatment option to reduce PVC frequency and symptoms, as supported by the 2017 AHA/ACC/HRS guideline 1.

Key Considerations

• The presence of frequent PVCs, defined as more than 30 PVCs per hour or at least 1 PVC on a 12-lead ECG, is associated with increased cardiovascular risk and mortality 1.
• Management strategies depend on the patient's symptoms and underlying cardiac function, with asymptomatic patients potentially requiring only regular monitoring if they have normal heart function.
• Symptomatic patients may benefit from beta-blockers, such as metoprolol (25-100 mg twice daily), as a first-line treatment to reduce PVC frequency and alleviate symptoms.
• Other treatment options include calcium channel blockers like diltiazem (120-360 mg daily) or antiarrhythmic medications such as amiodarone (200 mg daily after loading) for more severe cases or when first-line treatments are ineffective.
• Identifying and treating underlying conditions (e.g., electrolyte imbalances, thyroid dysfunction, structural heart disease) and avoiding triggers (caffeine, alcohol, stress) are crucial components of management.

Catheter Ablation Consideration

• For patients with very frequent PVCs (>10-15% of total beats) or those experiencing significant symptoms despite medication, catheter ablation may be considered as a treatment option, given its potential to effectively treat PVC-induced cardiomyopathy, as indicated by a prospective study where ablation was completely successful in 80% of patients 1.
• The decision to proceed with catheter ablation should be based on a comprehensive evaluation of the patient's condition, including the burden of PVCs, presence of LV dysfunction, and response to initial treatments.

Quality of Life and Morbidity Considerations

• The goal of treatment is not only to reduce the frequency of PVCs but also to improve the patient's quality of life by alleviating symptoms and preventing potential long-term complications such as cardiomyopathy.
• Regular follow-up and monitoring are essential to adjust treatment strategies as needed and to promptly address any changes in the patient's condition or the emergence of new symptoms.

From the Research

Sinus Rhythm with Frequent PVCs and Ventricular Trigeminy

• Sinus rhythm with frequent premature ventricular complexes (PVCs) and ventricular trigeminy can be associated with left atrial enlargement in patients with normal left ventricular ejection fraction, as shown in a study published in 2014 2.
• The study found that patients with frequent PVCs had significantly larger left atrial volume index, larger left ventricular end-diastolic dimension, lower left ventricular ejection fraction, and lower peak systolic mitral annular velocity compared to those without frequent PVCs.
• Frequent PVCs can also be a risk factor for heart failure and death, and the resolution of systolic dysfunction after successful catheter ablation of PVCs demonstrates that a causal relationship can be present 3.
• The prognosis of those with PVCs is variable, with ongoing uncertainty regarding the most informative predictors of adverse outcomes, and 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, and patient preference plays a role in determining which to try first 3, 4.
• Beta-blockers can reduce mortality in patients with heart failure with reduced ejection fraction in sinus rhythm, regardless of baseline heart rate, and achieving a lower heart rate is associated with better prognosis, but only for those in sinus rhythm 5.

Diagnostic and Therapeutic Considerations

• Identification of PVC burden is important, since cardiomyopathy and left ventricular dysfunction can reverse after catheter ablation or pharmacological suppression 4.
• Diagnostic procedures such as physical examination, electrocardiogram, ambulatory monitoring, exercise testing, echocardiography, cardiac magnetic resonance imaging, coronary angiography, and electrophysiology study can help differentiate benign and malignant PVCs 4.
• Treatment options include lifestyle modification, electrolyte imbalance correction, medical treatment, and catheter ablation, and the choice of treatment depends on the underlying cause and severity of the PVCs 3, 4.