What is the best course of treatment for a patient who is overweight (body mass index (BMI) > 25) without diabetes, experiencing premature ventricular contractions (PVCs)?

Management of Overweight Patient with Premature Ventricular Contractions (PVCs)

For an overweight patient (BMI >25) without diabetes experiencing premature ventricular contractions (PVCs), the best treatment approach is a comprehensive lifestyle intervention focused on weight loss through diet and physical activity, with consideration of pharmacological weight management if needed, while monitoring and treating PVCs based on their frequency and symptoms.

Assessment of PVCs

• PVCs are common cardiac arrhythmias that increase in frequency with age and may be present in about 50% of all people with or without heart disease 1
• Evaluate PVC burden, as frequent PVCs (generally >15% of total beats) may produce a reversible form of left ventricular dysfunction 1
• Assess for symptoms and determine if PVCs are associated with declining ventricular function, which would require more aggressive treatment 1
• Evaluate PVC characteristics including burden, duration, presence of nonsustained ventricular tachycardia, and multiform PVCs, as these factors are associated with risk of cardiomyopathy 2

Weight Management Approach

First-Line: Lifestyle Modifications

• Implement a comprehensive lifestyle intervention including caloric restriction and increased physical activity for at least 6-12 months 1
• Target a healthy weight with BMI of 18.5-25 kg/m², with initial goal of 5-10% weight loss 1
• Recommend a Mediterranean or similar diet with limited caloric intake and regular physical activity 1
• Regular physical activity reduces cardiovascular risk with an inverse relationship between moderate-to-vigorous physical activity and cardiovascular mortality 1
• Incorporate a structured exercise program with at least 30 minutes of moderate-intensity activity on most days of the week 1

Second-Line: Pharmacological Weight Management

• If weight targets are not reached with lifestyle modifications alone, consider pharmacological treatment with GLP-1 receptor agonists 1
• For patients with BMI ≥30 kg/m² or BMI ≥27 kg/m² with weight-related comorbidities, weight loss medications can be considered as an adjunct to lifestyle changes 1
• The SELECT trial showed significant reduction in cardiovascular events in patients with pre-existing cardiovascular disease who were overweight/obese but without diabetes when treated with semaglutide 1
• Tirzepatide has shown significant weight loss benefits in obese adults without diabetes in the SURMOUNT trials 1

Management of PVCs

Monitoring and Assessment

• Monitor PVC burden through Holter monitoring or other extended ECG monitoring 2
• Assess for risk factors of PVC-induced cardiomyopathy, including PVC burden >15%, longer PVC duration, presence of nonsustained VT, and multiform PVCs 2, 3
• Higher BMI (>30 kg/m²) is an independent predictor of PVC-induced cardiomyopathy, further emphasizing the importance of weight management 3

Treatment Options for PVCs

• For symptomatic PVCs or those associated with declining ventricular function:
  • Pharmacological treatment with beta blockers or amiodarone is reasonable to reduce arrhythmias and improve symptoms and LV function 1
  • For patients with frequent PVCs (>15% of beats) where medications are ineffective, not tolerated, or not preferred, catheter ablation is useful 1
• For asymptomatic PVCs with normal ventricular function, treatment may not be necessary, but monitoring for development of cardiomyopathy is important 1

Integrated Approach and Follow-up

• Implement a regular follow-up schedule to monitor both weight management progress and cardiac status 1
• Assess efficacy of weight management interventions at least monthly for the first 3 months, then every 3 months 1
• For patients with NAFLD (common in overweight individuals), be aware of the increased risk of ventricular arrhythmias 4
• Consider the relationship between weight loss and improvement in PVCs, as weight reduction may help reduce arrhythmia burden 3
• If PVC burden remains high despite weight loss, reassess need for antiarrhythmic therapy or ablation 1

Potential Pitfalls and Caveats

• Avoid class I sodium channel-blocking antiarrhythmic medications in post-MI patients or those with reduced LVEF as they increase mortality risk 1
• Be aware that some weight loss medications may have cardiovascular effects that could impact arrhythmia management 1
• Remember that it may be difficult to determine whether PVCs caused LV dysfunction or whether progressive LV dysfunction caused frequent PVCs 1
• Weight loss interventions alone are not sufficient - they should be viewed as tools that require sustained lifestyle changes for ultimate success 1