What does a Holter reading indicating sinus rhythm with occasional ventricular (VPCs) and atrial (APCs) ectopic beats mean in a patient with palpitations?

From the Guidelines

A Holter reading indicating sinus rhythm with occasional ventricular (VPCs) and atrial (APCs) ectopic beats in a patient with palpitations is generally considered benign and does not typically require specific treatment, especially if the patient has no underlying structural heart disease, as supported by the 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1.

The presence of VPCs and APCs on a Holter reading is common and can be found in about 50% of all people with or without heart disease, increasing in frequency with age 1. The patient's Holter reading shows a mean heart rate of 60 bpm, ranging from 44 to 88 bpm, with infrequent ventricular ectopy (671) and infrequent atrial ectopy (284), which is consistent with a benign finding. The patient also reported unusual heart rhythm periods, which correlated with the ventricular and ectopic beats, suggesting that these beats may be causing the patient's symptoms of palpitations.

The guideline recommends that patients with frequent PVCs, defined as at least 1 PVC on a 12-lead ECG or >30 PVCs per hour, should be evaluated to ensure they do not have underlying conditions that warrant further treatment to reduce risk 1. However, in this case, the patient's PVCs and APCs are infrequent, and there is no indication of underlying structural heart disease. Therefore, lifestyle modifications, such as limiting caffeine, alcohol, and nicotine, managing stress, getting adequate sleep, and staying hydrated, may be sufficient to reduce symptoms.

If symptoms are bothersome, medications like beta-blockers (such as metoprolol 25-100 mg twice daily) or calcium channel blockers (such as diltiazem 120-360 mg daily) might be prescribed to reduce the frequency of these ectopic beats, as they work by slowing the heart rate and reducing the excitability of heart tissue. Further cardiac evaluation may be warranted if the ectopic beats are very frequent or if the patient has underlying heart disease. However, based on the provided Holter reading and the patient's symptoms, no specific treatment is typically needed at this time, and the patient can be reassured that their heart is primarily beating in a normal rhythm.

From the Research

Holter Reading Interpretation

The Holter reading indicates that the patient is in sinus rhythm with a mean heart rate of 60bpm, ranging from 44 to 88 bpm. The resting ECG also shows sinus rhythm at 54 bpm.

Ectopic Beats

• Infrequent ventricular ectopy (671) and infrequent atrial ectopy (284) were observed.
• There were 4 atrial pairs and 3 short atrial runs, with the longest and maximum run being 7 beats at 110 beats/min.
• According to 2, atrial ectopics are a common finding on Holter ECG monitoring and are generally considered innocent in the otherwise normal heart, but may be a harbinger to more serious atrial tachyarrhythmias in patients with heart disease.

Symptom Correlation

• The patient pressed the symptom event button 4 times on the Holter recorder, reporting unusual heart rhythm periods that correlated to the ventricular and ectopic beats.
• As stated in 3, palpitations can be caused by cardiac arrhythmias, including premature ventricular contractions, and can also be associated with nonarrhythmic cardiac problems and noncardiac problems.

Clinical Significance

• The presence of ventricular and atrial ectopic beats may be contributing to the patient's symptoms of palpitations, as seen in 4, where ventricular ectopic beats led to functional ventricular undersensing.
• However, as noted in 5, a careful reinterpretation of the ECG and further evaluation may be necessary to determine the underlying cause of the palpitations.
• The use of extended electrocardiogram monitoring, such as 24-hour Holter monitoring, can be helpful in documenting arrhythmias and making a diagnosis, as discussed in 6.

No Sustained Tachyarrhythmias or Bradyarrhythmias

• No sustained tachyarrhythmias, bradyarrhythmias, or prolonged pauses were documented during the Holter monitoring period.
• This suggests that the patient's heart rhythm is generally stable, but the presence of ectopic beats and symptoms of palpitations warrant further evaluation and monitoring.