What is the workup for frequent premature ventricular contractions (PVCs)?

From the Guidelines

The workup for frequent premature ventricular contractions (PVCs) should begin with a thorough history and physical examination, followed by a 12-lead ECG to document the PVCs, and additional testing including a 24-hour Holter monitor or longer-term event monitor to quantify PVC burden. This approach is based on the latest guidelines and evidence, including the 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1. The evaluation should also include laboratory tests to assess for electrolyte abnormalities, thyroid function, and anemia, as well as an echocardiogram to evaluate cardiac structure and function. Exercise stress testing may help determine if PVCs increase or decrease with exertion, and for patients with concerning symptoms, family history of sudden cardiac death, or structural heart disease, cardiac MRI or coronary angiography may be indicated. Management depends on symptom severity, PVC burden, and presence of structural heart disease, ranging from reassurance for benign cases to antiarrhythmic medications or catheter ablation for symptomatic or high-burden cases. It is essential to note that treatment of PVCs with antiarrhythmic medications has not been shown to reduce mortality, and in some cases, may even increase the risk of death 1. Therefore, a careful and individualized approach is necessary, taking into account the patient's specific clinical context and risk factors. In athletes, the presence of multiple PVCs on an ECG should prompt more extensive evaluation to exclude underlying structural heart disease, including ambulatory Holter monitoring, echocardiogram, and exercise stress test 1. Overall, the goal of the workup and management of frequent PVCs is to identify and address any underlying conditions that may be contributing to the arrhythmia, and to reduce the risk of adverse cardiovascular outcomes. Key considerations in the workup and management of frequent PVCs include:

• Quantifying PVC burden using a 24-hour Holter monitor or longer-term event monitor
• Evaluating cardiac structure and function using an echocardiogram
• Assessing for underlying conditions such as electrolyte abnormalities, thyroid dysfunction, and anemia
• Considering cardiac MRI or coronary angiography in patients with concerning symptoms or structural heart disease
• Individualizing management based on symptom severity, PVC burden, and presence of structural heart disease.

From the Research

Frequent PVCs Workup

• The workup for frequent premature ventricular complexes (PVCs) involves a comprehensive evaluation of the patient's clinical presentation, medical history, and diagnostic test results 2, 3.
• The initial workup may include a physical examination, electrocardiogram, ambulatory monitoring, exercise testing, echocardiography, and cardiac magnetic resonance imaging to assess for underlying structural heart disease and to determine the burden of PVCs 4.
• The evaluation should also consider the patient's symptoms, medical history, and risk factors for cardiomyopathy and sudden cardiac death 2, 3.

Diagnostic Considerations

• The diagnosis of frequent PVCs is typically made based on the presence of PVCs on an electrocardiogram or ambulatory monitoring 2, 3.
• The burden of PVCs can be quantified using ambulatory monitoring or echocardiography, and a burden of ≥5% is considered significant 5.
• The presence of underlying structural heart disease, such as cardiomyopathy or coronary artery disease, should be assessed using echocardiography, cardiac magnetic resonance imaging, or coronary angiography 4.

Management

• The management of frequent PVCs depends on the patient's symptoms, medical history, and risk factors for cardiomyopathy and sudden cardiac death 2, 3.
• Lifestyle modification, such as avoiding caffeine and alcohol, and medical therapy, such as beta-blockers or antiarrhythmic drugs, may be effective in reducing PVC burden 5.
• Catheter ablation may be considered for patients with symptomatic PVCs who have failed medical therapy or have a high burden of PVCs 4.