What is the management approach for premature ventricular contractions (PVCs) onset specifically tied to the Assurity device?

Management of PVCs Associated with Assurity™ Device

For premature ventricular contractions (PVCs) specifically tied to the Assurity™ device, beta-blocker therapy should be initiated as first-line treatment, with catheter ablation considered if medical therapy fails or if PVC burden exceeds 15%. 1

Diagnostic Evaluation

1. Quantify PVC burden with 24-hour Holter monitoring to establish:

   • Frequency of PVCs (percentage of total beats)
   • Pattern and morphology
   • Correlation with Assurity™ device function

2. Risk stratification based on PVC burden:

   • <10%: Low risk for cardiomyopathy
   • 10-15%: Intermediate risk

   • 15%: High risk

   • ≥24%: Extremely high risk (independently associated with cardiomyopathy) 1

3. Assess for symptoms:

   • Palpitations
   • Dizziness
   • Chest discomfort
   • Impact on quality of life

4. Evaluate for structural heart disease with echocardiography

Treatment Algorithm

Step 1: Medical Therapy

• First-line: Beta-blockers

  • Start with propranolol 10-20mg three times daily
  • Can be titrated up to 40-80mg three times daily
  • Regular scheduled dosing (not as-needed)
  • Consider extended-release formulations for improved adherence 1

• Alternative if beta-blockers are contraindicated or ineffective:

  • Non-dihydropyridine calcium channel blockers (verapamil or diltiazem) 1
  • Class I or III antiarrhythmic medications (second-line therapy) 1

Step 2: Catheter Ablation

• Consider ablation if:

  • Medical therapy fails to control symptoms
  • Patient is drug-resistant or drug-intolerant
  • Patient prefers not to take long-term medication
  • PVC burden >15% (strong indication if >24%) 1, 2

• Ablation is particularly indicated for:

  • Symptomatic patients with frequent predominantly monomorphic PVCs 3
  • Patients at risk for PVC-induced cardiomyopathy (burden >20%) 2

Special Considerations for Device-Related PVCs

1. Device Interrogation and Reprogramming:

   • Evaluate if specific device settings are triggering PVCs
   • Consider adjusting pacing parameters if associated with PVC onset

2. Monitor for PVC-Induced Cardiomyopathy:

   • Annual cardiac evaluation with echocardiography
   • More frequent monitoring if PVC burden is high (>15%)
   • Watch for declining left ventricular function 1, 4

3. Lifestyle Modifications:

   • Limit caffeine, alcohol, and stimulants
   • Manage stress and anxiety
   • Consider limiting high-intensity physical activities if PVC burden is high 1

Clinical Pearls and Pitfalls

• Important: PVCs that were previously considered benign are now recognized as potential causes of cardiomyopathy when frequent (>10-15% burden) 4, 5

• Caution: Beta-blockers should be used carefully or avoided in patients with:

  • Asthma or reactive airway disease
  • Decompensated heart failure
  • Significant bradycardia or heart block
  • Severe peripheral vascular disease 1

• Follow-up: Repeat Holter monitoring after initiating therapy to assess response and adjust treatment accordingly 1

• Warning sign: If PVCs increase with exercise, this may indicate underlying structural heart disease and warrants further evaluation 1