From the Guidelines
A patient with ECG-confirmed ventricular premature complexes (VPCs) should be referred to a cardiologist for evaluation, as VPCs can be associated with underlying heart disease and increased risk of adverse cardiovascular outcomes, as noted in the 2018 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1. The cardiologist will likely:
- Perform a thorough history and physical examination
- Order additional tests such as:
- 24-hour Holter monitor
- Echocardiogram
- Exercise stress test
- Blood tests to check electrolytes and thyroid function Treatment depends on the frequency of VPCs, associated symptoms, and underlying heart condition. Options may include:
- Observation for asymptomatic, infrequent VPCs
- Beta-blockers (e.g., metoprolol 25-100 mg twice daily) for symptomatic patients, as beta-blockers have been shown to be effective in reducing symptoms and improving quality of life in patients with VPCs 1
- Antiarrhythmic drugs like amiodarone (200-400 mg daily) for frequent, symptomatic VPCs, although the use of antiarrhythmic medications should be approached with caution due to the potential for increased risk of death, as noted in the CAST trials 1
- Catheter ablation for drug-refractory cases, which can be an effective treatment option for patients with frequent, symptomatic VPCs, as noted in the 2019 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases 1 Cardiology referral is important because VPCs can sometimes indicate underlying heart disease or be a precursor to more serious arrhythmias, and a cardiologist can determine the clinical significance of the VPCs and provide appropriate management to reduce symptoms and potential complications, as emphasized in the 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1.
From the Research
Patient Evaluation
- A patient with ventricular premature complexes (VPCs) on an electrocardiogram (ECG) may require a cardiology consultation, as VPCs can be associated with worse prognosis and higher morbidity and mortality 2.
- The diagnostic work-up for VPCs includes a 12-lead ECG to characterize QRS morphology, Holter monitor to assess frequency, and echo and advanced imaging to assess for early cardiomyopathy and exclude structural heart disease 2, 3.
Treatment Options
- Treatment options for VPCs include watchful waiting, medical therapy, or catheter ablation 2, 3.
- Medical therapy may include β-blockers or nondihydropyridine calcium channel blockers for patients with normal ventricular systolic function 3.
- Catheter ablation is the most efficacious approach to eradicate VPCs, but may confer increased upfront risks 3.
- Ranolazine, a piperazine derivative, has been used to treat symptomatic VPCs and ventricular tachycardia in patients with ischemic cardiomyopathy 4.
Risk Factors and Prognosis
- Increasing age, taller height, higher blood pressure, history of heart disease, less physical activity, and smoking are predictors of a greater VPC frequency 3.
- A high VPC burden may induce cardiomyopathy and left ventricular dysfunction, or worsen underlying cardiomyopathy 3, 5.
- The prognosis of patients with VPCs is variable, with ongoing uncertainty regarding the most informative predictors of adverse outcomes 3.