What is the treatment for extrasystoles (premature heartbeats)?

Treatment of Extrasystoles (Premature Heartbeats)

For benign extrasystoles, first-line management involves identifying and eliminating precipitating factors such as excessive caffeine, alcohol, nicotine intake, recreational drugs, or hyperthyroidism, as these interventions can significantly reduce symptoms without medication. 1

Initial Evaluation and Classification

• Determine if extrasystoles are supraventricular (SVEs) or ventricular (VEs) through ECG evaluation 1
• Assess for underlying structural heart disease with echocardiography, as this significantly impacts treatment approach and prognosis 1
• Benign extrasystoles are often more noticeable at rest and tend to decrease with exercise 1
• Patients typically describe extrasystoles as pauses or skipped beats followed by a sensation of a strong heartbeat 1

Treatment Algorithm for Supraventricular Extrasystoles (SVEs)

• For asymptomatic patients with isolated SVEs and no structural heart disease:

  • No specific treatment is required 2
  • Monitor patients with frequent SVEs and cardiovascular risk factors as they may have increased risk for atrial fibrillation 2

• For symptomatic patients with SVEs:

  • First step: Eliminate triggering factors (caffeine, alcohol, stress) 1
  • Second step: Consider beta-blockers for symptom control if lifestyle modifications are insufficient 1
  • Vagal maneuvers may be taught to patients to terminate episodes of tachycardia if SVEs trigger paroxysmal SVT 1

Treatment Algorithm for Ventricular Extrasystoles (VEs)

• For asymptomatic patients with VEs:

  • No treatment needed if VE burden is <5% of total heartbeats and no structural heart disease is present 2
  • Regular monitoring is appropriate for those with higher VE burden 3

• For symptomatic patients with VEs:

  • First step: Eliminate triggering factors (caffeine, alcohol, stress) 1
  • Second step: Beta-blockers may be prescribed empirically provided significant bradycardia (<50 bpm) has been excluded 1
  • For patients with severe symptoms despite medical therapy:
    • Catheter ablation is now first-line treatment for symptomatic idiopathic VEs, particularly those originating from the right ventricular outflow tract (RVOT) 2, 4

Important Considerations

• Antiarrhythmic treatment with Class I or Class III drugs should not be initiated without documented arrhythmia due to risk of proarrhythmia 1
• Catheter ablation has a success rate of approximately 70-76% regardless of the anatomical site of VEs 4
• Patients with higher BMI may have lower success rates with catheter ablation procedures 4
• Complications from catheter ablation are rare (approximately 4.5%) and typically related to catheter insertion sites 4

Special Situations

• For patients with VEs and structural heart disease (particularly ischemic heart disease):

  • More aggressive treatment is warranted due to increased risk of sudden cardiac death 3
  • Treatment is indicated if VE frequency is >10 per hour on 24-hour Holter monitoring 3

• For patients with tachycardia-induced cardiomyopathy from frequent extrasystoles:

  • More aggressive rhythm control is needed as ventricular dysfunction correlates with duration and rate of arrhythmia 1
  • Reversibility of cardiomyopathy is possible with effective treatment of the arrhythmia 1

Prognosis

• Isolated extrasystoles in structurally normal hearts generally carry a good prognosis 5
• Even patients with right ventricular extrasystoles and minor echocardiographic abnormalities have favorable long-term outcomes 5
• Multiform extrasystoles with variable coupling intervals may indicate more serious underlying conduction abnormalities and warrant closer monitoring 6