What is the best course of action for a 27-year-old female patient with a history of palpitations, lightheadedness, and dizziness, currently taking Bupropion Hydrochloride (Wellbutrin) ER 300 mg daily, Lisdexamfetamine Dimesylate (Vyvanse) 30 mg daily, and Drospirenone-Ethinyl Estradiol (Yaz) 3-0.02 mg daily, who recently experienced frequent premature ventricular contractions (PVCs) and anxiety?

Management of Frequent PVCs in a Young Patient on Stimulant Medications

The most critical first step is to discontinue or reduce the Vyvanse (lisdexamfetamine) and Wellbutrin (bupropion), as both medications are known to cause palpitations, tachycardia, and can exacerbate ventricular arrhythmias, particularly in combination. 1, 2, 3

Immediate Medication Management

Stimulant and Antidepressant Considerations

• Lisdexamfetamine (Vyvanse) should be discontinued or dose-reduced given the FDA warning that it increases blood pressure and heart rate, and should be avoided in patients with serious cardiac arrhythmias 1
• The patient's recent ER visit with frequent PVCs while on Vyvanse 30 mg daily strongly suggests a medication-induced component to her arrhythmia 1
• Bupropion can cause tachycardia and palpitations, with dose-related cardiovascular effects including increased supine blood pressure 2, 3
• The combination of both medications likely creates additive sympathomimetic effects that are triggering her PVCs 1, 2

Oral Contraceptive Assessment

• Drospirenone-ethinyl estradiol (Yaz) is generally well-tolerated from a cardiac standpoint and is unlikely to be contributing to her PVCs 4, 5
• This medication can be continued unless other contraindications arise 5

Pharmacological Treatment for PVCs

Beta-Blocker Therapy (First-Line)

If PVCs persist after stimulant discontinuation, initiate beta-blocker therapy as the primary treatment for symptomatic PVCs. 6

• Metoprolol 25-100 mg daily or twice daily is reasonable for PVC suppression 6
• Alternative options include:
  • Nadolol 40-320 mg daily (longer half-life, may provide more consistent suppression) 6
  • Propranolol 10-40 mg four times daily or 60-160 mg extended-release twice daily 6
• Beta-blockers slow sinus rate and increase AV nodal refractoriness, effectively suppressing PVCs 6

Alternative Antiarrhythmic Agents

If beta-blockers are ineffective or not tolerated:

• Flecainide 50-200 mg twice daily can be used for PVCs in the absence of structural heart disease (which this patient has confirmed with normal echocardiogram) 6
• Propafenone 150-300 mg three times daily is another option for structurally normal hearts 6

Important caveat: Class IC agents (flecainide, propafenone) are contraindicated in patients with structural heart disease or prior myocardial infarction due to increased mortality risk 6

When to Consider Catheter Ablation

Catheter ablation is indicated (Class I recommendation) if:

• PVCs persist despite medication discontinuation and beta-blocker therapy 6
• PVC burden exceeds 15% of total beats with a single consistent morphology 6
• There is evidence of declining ventricular function (though her EF is currently normal at 64%) 6
• The patient prefers ablation over long-term medication therapy 6

Monitoring Strategy

Short-Term (Next 2-4 Weeks)

• Discontinue or significantly reduce Vyvanse dose immediately 1
• Consider switching from bupropion to an alternative antidepressant with less cardiovascular effect (e.g., SSRI) 2, 3
• Repeat ambulatory monitoring (24-48 hour Holter or event monitor) 2-4 weeks after medication changes to assess PVC burden 6

Long-Term Follow-Up

• If PVCs resolve with medication discontinuation, no further cardiac intervention is needed 6
• If PVCs persist with burden >10-15%, repeat echocardiogram in 6-12 months to assess for PVC-induced cardiomyopathy 6
• Annual follow-up with cardiology if PVCs continue but remain asymptomatic 6

Critical Pitfalls to Avoid

• Do not continue both stimulant medications while attempting to treat PVCs pharmacologically - this addresses the symptom while perpetuating the cause 1, 2
• Avoid calcium channel blockers (verapamil, diltiazem) for wide-complex tachycardia of unknown origin as they can cause hemodynamic collapse if the rhythm is actually ventricular in origin 6
• Do not use Class IC antiarrhythmics if any structural heart disease develops - repeat echocardiogram before initiating these agents 6
• Avoid abrupt beta-blocker discontinuation if started, as this can cause rebound tachycardia 7

Addressing Anxiety Component

• The patient's anxiety appears to be both a trigger for and consequence of her palpitations 1
• Consider switching to an SSRI or SNRI (which have less arrhythmogenic potential than bupropion) for both depression and anxiety management 2, 3
• Cognitive behavioral therapy may help reduce anxiety-triggered palpitation episodes 1