What is the clinical significance of an average heart rate of 75 beats per minute (bpm), nonsustained ventricular tachycardia (VT) lasting 11 beats, no episodes of atrial fibrillation or flutter, no high-grade atrioventricular (AV) block, premature atrial contraction (PAC) burden of 1%, and premature ventricular contraction (PVC) burden of 6% in an 86-year-old female?

From the Guidelines

The 86-year-old female patient's Holter monitor results indicate a need for cardiology consultation to assess for underlying structural heart disease and potential treatment options due to the presence of nonsustained ventricular tachycardia (NSVT) and a moderately elevated premature ventricular contraction (PVC) burden of 6%. The patient's average heart rate of 75 beats per minute, PAC burden of 1%, and absence of atrial fibrillation, flutter, or high-grade AV block are also important considerations in her evaluation. According to the 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1, the presence of PVCs, particularly if multifocal and frequent, is generally considered a risk factor for adverse cardiovascular outcomes.

The patient's PVC burden of 6% is notable, as frequent PVCs have been associated with increased cardiovascular risk and mortality 1. The guideline also highlights that treatment of PVCs with antiarrhythmic medications has not been shown to reduce mortality, and in some cases, may even increase the risk of death 1. However, beta blockers, such as metoprolol, may be considered as a treatment option if the patient is symptomatic.

Given the patient's advanced age and the presence of NSVT, it is essential to assess for underlying structural heart disease through an echocardiogram and possibly cardiac MRI. Regular follow-up with cardiology is crucial to track any progression of the arrhythmia burden or development of sustained ventricular arrhythmias. The patient should be monitored for symptoms like palpitations, dizziness, or syncope, which would indicate worsening of the arrhythmia.

Key considerations in the patient's management include:

• Assessment for underlying structural heart disease
• Potential treatment options, such as beta blockers or calcium channel blockers, if symptomatic
• Regular follow-up with cardiology to track progression of the arrhythmia burden
• Monitoring for symptoms that may indicate worsening of the arrhythmia.

From the Research

Clinical Significance of Cardiac Arrhythmias

The clinical significance of an average heart rate of 75 beats per minute (bpm), nonsustained ventricular tachycardia (VT) lasting 11 beats, no episodes of atrial fibrillation or flutter, no high-grade atrioventricular (AV) block, premature atrial contraction (PAC) burden of 1%, and premature ventricular contraction (PVC) burden of 6% in an 86-year-old female can be understood through the following points:

• Nonsustained ventricular tachycardia (NSVT) is associated with an increased risk for sudden death, particularly in patients with congestive heart failure (CHF) due to cardiomyopathy 2.
• The presence and frequency of NSVT are markers for increased risk of sudden cardiac death, although the effectiveness of antiarrhythmic drugs in preventing this outcome is uncertain 2, 3.
• Premature ventricular contractions (PVCs) and NSVT can increase the risk for sustained ventricular tachycardia, ventricular fibrillation, and sudden cardiac death, especially in patients with primary cardiomyopathy or tachycardia-induced cardiomyopathy 3.
• Medical therapy, including beta-blockers and class III anti-arrhythmic agents, can be effective in managing PVCs and NSVT, while implantable cardiac defibrillators (ICDs) are indicated in certain patients 3, 4.
• The patient's age and comorbidities, such as congestive heart failure, should be considered when deciding on the treatment approach, with a focus on improving quality of life and reducing symptoms 5, 6.

Risk Stratification and Management

The patient's risk stratification and management can be considered based on the following points:

• The patient's PVC burden of 6% and NSVT may indicate an increased risk for sudden cardiac death, and further evaluation and management may be necessary 2, 3.
• The absence of atrial fibrillation or flutter and high-grade AV block is positive, but the patient's overall cardiac function and comorbidities should be considered when determining the best course of treatment 4.
• The patient's age and comorbidities may affect the choice of treatment, with a focus on improving quality of life and reducing symptoms, rather than solely on reducing the risk of sudden cardiac death 5, 6.
• A multidisciplinary approach to care, including cardiology, geriatrics, and palliative care, may be necessary to address the patient's complex needs and improve overall outcomes 5.