What is the treatment for premature ventricular contractions (PVCs)?

From the Guidelines

For patients with premature ventricular contractions (PVCs) who require arrhythmia suppression for symptoms or declining ventricular function, catheter ablation is useful, especially when PVCs are frequent (generally >15% of beats) and predominately of one morphology, as stated in the 2017 AHA/ACC/HRS guideline 1.

Treatment Approach

The treatment approach for PVCs depends on their frequency, symptoms, and underlying causes. For most people with occasional PVCs who are otherwise healthy, no treatment is necessary beyond lifestyle modifications such as reducing caffeine, alcohol, and stress.

• When PVCs cause significant symptoms or occur frequently, medical intervention may be warranted.
• First-line medications include beta-blockers like metoprolol or calcium channel blockers such as diltiazem.
• For more severe cases, antiarrhythmic drugs like flecainide or amiodarone may be prescribed, as suggested by the 2015 ESC guidelines for the management of patients with ventricular arrhythmias 1.

Catheter Ablation

In cases where PVCs originate from a specific focus and are refractory to medication, catheter ablation is recommended, especially for symptomatic patients or those with a decline in LV function due to PVC burden, with a success rate of 80-90% for eliminating PVCs 1.

Underlying Conditions

It's also essential to address any underlying conditions such as heart disease, electrolyte abnormalities, or thyroid disorders that may be triggering the PVCs. Regular cardiac monitoring may be necessary to assess treatment effectiveness and adjust therapy accordingly.

• The 2017 AHA/ACC/HRS guideline recommends pharmacologic treatment, such as beta blockers or amiodarone, to reduce recurrent arrhythmias, improve symptoms, and improve LV function in patients with PVC-induced cardiomyopathy 1.
• The choice of treatment should be individualized based on the patient's specific condition, symptoms, and response to therapy.

From the FDA Drug Label

Flecainide acetate causes a dose-related and plasma-level related decrease in single and multiple PVCs and can suppress recurrence of ventricular tachycardia. Propafenone causes a dose-related and concentration-related decrease in the rate of single and multiple premature ventricular contractions (PVCs) and can suppress recurrence of ventricular tachycardia.

The treatment for premature ventricular contractions (PVCs) includes the use of antiarrhythmic medications such as flecainide and propafenone. These medications can help decrease the rate of single and multiple PVCs and suppress the recurrence of ventricular tachycardia.

• Flecainide has been shown to be effective in suppressing PVCs, with plasma levels of 0.2 to 1 mcg/mL needed to obtain the maximal therapeutic effect 2.
• Propafenone also causes a dose-related and concentration-related decrease in the rate of single and multiple PVCs, with trough plasma levels of 0.2 to 1.5 µg/mL providing good suppression 3.

From the Research

Treatment Options for Premature Ventricular Contractions (PVCs)

• Medications:
  • Antiarrhythmic drugs such as propafenone, flecainide, and sotalol have been shown to be effective in reducing PVC burden 4, 5
  • Beta-blockers like metoprolol and carvedilol may be used, but their efficacy can be limited and they may even be proarrhythmic in some cases 6
• Catheter ablation:
  • Radiofrequency catheter ablation (RFCA) has been shown to be effective in eliminating PVCs, especially in patients with idiopathic PVCs 4, 7
  • This procedure involves using energy to destroy the abnormal electrical pathways in the heart that are causing the PVCs
• Lifestyle modifications:
  • Addressing reversible causes such as stress, anxiety, and caffeine intake may help reduce PVC frequency 8
  • Clinical observation and monitoring may be recommended for patients with asymptomatic PVCs or those with a low PVC burden

Efficacy of Different Treatment Options

• Propafenone has been shown to be more effective than verapamil and metoprolol in suppressing idiopathic PVCs 4
• Flecainide has been found to be the most effective antiarrhythmic drug in achieving complete or near-complete reduction of PVC burden 5
• RFCA has been shown to be effective in eliminating PVCs in a high percentage of patients, with a low risk of complications 4, 7

Patient-Specific Factors

• The presence or absence of underlying heart disease can affect the prognosis and management of PVCs 8
• PVC burden and frequency can also impact the choice of treatment and the likelihood of success 8, 6
• Patient symptoms and quality of life should be taken into account when determining the best course of treatment 4, 5, 8