Do frequent premature ventricular contractions (PVCs) have prognostic significance for perioperative patients?

From the Guidelines

Frequent premature ventricular contractions (PVCs) can have prognostic significance for perioperative patients, particularly in those with underlying structural heart disease, as they may indicate increased risk for perioperative arrhythmias and adverse cardiac events. The presence of PVCs on 2 minutes of monitoring of middle-aged patients in the ARIC study was associated with increased risk of both ischemic heart disease events and mortality, with or without prevalent ischemic heart disease 1. In the general population, frequent PVCs, which are defined as the presence of at least 1 PVC on a 12-lead ECG or >30 PVCs per hour, are associated with increased cardiovascular risk and increased mortality 1.

Key Considerations

• Preoperative evaluation should include assessment of underlying cardiac disease, electrolyte abnormalities, and medication effects that might exacerbate PVCs.
• For high-risk patients with frequent PVCs and structural heart disease, perioperative beta-blockers (such as metoprolol 25-100 mg twice daily) may be considered, starting at least 24 hours before surgery if possible 1.
• Correction of electrolyte abnormalities (particularly potassium >4.0 mEq/L and magnesium >2.0 mg/dL) is essential to reduce the risk of arrhythmias 1.
• Continuous cardiac monitoring should be implemented during and after surgery for patients with concerning PVC patterns.

Management of PVCs

• Unifocal or multifocal premature ventricular contractions do not merit therapy unless they are symptomatic or result in hemodynamic compromise 1.
• Very frequent ventricular ectopy or prolonged runs of nonsustained ventricular tachycardia may require antiarrhythmic therapy if they are symptomatic or result in hemodynamic compromise 1.
• The management of ventricular arrhythmias should be based on the underlying cause and the presence of symptoms or hemodynamic compromise 1.

From the Research

Prognostic Significance of Frequent PVCs in Perioperative Patients

• Frequent premature ventricular complexes (PVCs) can lead to symptoms such as cardiomyopathy and increased mortality 2.
• High PVC burden may induce cardiomyopathy and left ventricular (LV) dysfunction or worsen underlying cardiomyopathy 3.
• An increased PVC frequency may be a risk factor for heart failure and death 4.
• The prognosis of those with PVCs is variable, with ongoing uncertainty regarding the most informative predictors of adverse outcomes 4.

Clinical Implications

• Identification of PVC burden is important, since cardiomyopathy and LV dysfunction can reverse after catheter ablation or pharmacological suppression 3.
• Patients with no or mild symptoms, a low PVC burden, and normal ventricular function may be best served with simple reassurance 4.
• 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 4.

PVCs in Perioperative Setting

• There is limited direct evidence on the prognostic significance of frequent PVCs specifically in perioperative patients.
• However, the available evidence suggests that frequent PVCs can have significant clinical implications, including increased risk of cardiomyopathy and mortality 2, 3, 4.
• Further research is needed to determine the prognostic significance of frequent PVCs in perioperative patients and to guide clinical management in this setting.