How to manage frequent polymorphic premature ventricular contractions (PVCs)?

From the Guidelines

Frequent polymorphic premature ventricular contractions (PVCs) should be managed with beta-blockers as the first-line treatment, with catheter ablation considered for patients with persistent symptoms or left ventricular dysfunction, as recommended by the 2017 AHA/ACC/HRS guideline 1.

Key Considerations

• Correcting electrolyte abnormalities, particularly potassium and magnesium deficiencies, is essential in managing PVCs.
• Beta-blockers like metoprolol or carvedilol are effective in suppressing PVCs by reducing sympathetic tone.
• For patients with structural heart disease, amiodarone may be used, but its efficacy and safety should be carefully evaluated.
• Catheter ablation is a useful option for patients with persistent symptoms or left ventricular dysfunction, especially when PVCs comprise >10% of total heartbeats, as stated in the 2017 AHA/ACC/HRS guideline executive summary 1.

Treatment Approach

• Identify and treat underlying causes of PVCs, such as coronary artery disease, cardiomyopathy, or channelopathies.
• Use beta-blockers as the first-line medication, with a dosage of 25-100 mg twice daily for metoprolol or 3.125-25 mg twice daily for carvedilol.
• Consider catheter ablation for patients with persistent symptoms or left ventricular dysfunction, as recommended by the 2017 AHA/ACC/HRS guideline 1.
• Regular cardiac monitoring is essential to assess treatment efficacy and detect progression to more dangerous arrhythmias, as polymorphic PVCs can sometimes precede torsades de pointes or ventricular fibrillation, particularly in patients with long QT syndrome or structural heart disease, as noted in the 2015 eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities 1.

Important Considerations

• Patients should avoid triggers like caffeine, alcohol, and stimulants, which can exacerbate PVCs.
• The frequency and pattern of PVCs should be evaluated using a 24-hour ambulatory monitor, as recommended in the 2015 eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities 1.
• PVCs recorded at a frequency of >2000 per 24 hours have a higher likelihood of association with underlying cardiac disease, estimated at 30% in this subgroup, as noted in the 2015 eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities 1.

From the Research

Management of Frequent Polymorphic Premature Ventricular Contractions (PVCs)

• The management of frequent polymorphic PVCs should focus on identifying and treating the underlying causes, such as electrolyte abnormalities, substance use, and underlying structural heart disease 2.
• Beta-blockers are considered first-line therapy for symptomatic PVCs, while nondihydropyridine calcium channel blockers, classic antiarrhythmic agents, and amiodarone can be considered as second-line agents 2, 3.
• Catheter ablation of the PVC focus is recommended for patients who are unable to tolerate medical therapy or have failed medical therapy, as it has been shown to reduce PVC burden and improve left ventricular ejection fraction (LVEF) in those with PVC-induced cardiomyopathy 2, 4.
• Patients with no evidence of structural heart disease and infrequent PVCs should be monitored closely, while those who are symptomatic should be treated medically 2.
• The prognosis of those with PVCs is variable, with ongoing uncertainty regarding the most informative predictors of adverse outcomes, but an increased PVC frequency may be a risk factor for heart failure and death 3.

Diagnostic Workup

• The diagnostic workup for PVCs includes electrocardiogram (ECG) and 24-h Holter monitor to assess the QRS morphology and its frequency 2.
• A transthoracic echocardiogram (TTE) is done to look for structural heart disease and cardiomyopathy 2, 4.
• Ambulatory monitoring is required to assess PVC frequency, and cardiac magnetic resonance imaging is helpful when the evaluation suggests the presence of associated structural heart disease 3.

Treatment Options

• Medical treatment, including beta-blockers and nondihydropyridine calcium channel blockers, is considered first-line therapy for symptomatic PVCs 2, 3.
• Catheter ablation is the most efficacious approach to eradicate PVCs, but may confer increased upfront risks 3.
• Suppression of PVCs by radiofrequency ablation or antiarrhythmic drugs (AADs) can improve myocardial function, cardiac chamber sizes, and patient's symptoms in PVC-associated cardiomyopathy 5.