What are the symptoms and treatment options for premature ventricular contractions (PVCs)?

Symptoms of Premature Ventricular Contractions (PVCs)

Most patients with PVCs are completely asymptomatic, and when symptoms do occur, they typically manifest as palpitations, lightheadedness, chest discomfort, or the sensation of skipped beats. 1

Symptom Spectrum

Asymptomatic Presentation

• Approximately 50% of all people have PVCs on extended monitoring, yet most remain completely unaware of them 2
• PVCs increase in frequency with age, found in only 0.6% of healthy individuals under 20 years but 2.7% of those over 50 years on standard ECG 2
• Asymptomatic PVCs generally do not require specific treatment 3

Symptomatic Presentation

When symptoms occur, patients typically experience:

• Palpitations (the most common symptom) 2, 1
• Sensation of skipped beats or "flip-flopping" in the chest 1
• Lightheadedness or dizziness 1
• Chest discomfort or pressure 1

High-Burden PVC Symptoms

When PVCs exceed 10,000-20,000 per day (>10-20% of total heartbeats):

• Fatigue and exertional dyspnea may develop 4
• Progressive heart failure symptoms can emerge (shortness of breath, exercise intolerance, lower extremity edema) 5
• These symptoms indicate possible PVC-induced cardiomyopathy with depressed left ventricular function 2

Severe/Malignant Presentations

• Syncope (loss of consciousness) may occur in rare cases 1
• Sudden cardiac death risk, though very rare in structurally normal hearts, can occur when idiopathic outflow tract PVCs trigger malignant ventricular arrhythmias 2

Clinical Context Matters

Structural Heart Disease

• In patients with diabetes and frequent PVCs, attempts to diagnose underlying structural heart disease should be considered 2
• PVCs during exercise testing are associated with higher mortality risk 2
• PVCs during recovery phase post-exercise are stronger predictors of death than those occurring only during exercise 2

Athletes

• Complex PVCs in endurance athletes may not be benign and warrant electrophysiological study to assess arrhythmogenic risk 2
• However, in trained athletes with palpitations but no other cardiovascular abnormalities, PVCs do not appear to increase death risk based on small studies 2

Treatment Approach Based on Symptoms

For Symptomatic PVCs

Beta blockers or non-dihydropyridine calcium channel blockers are first-line therapy to relieve palpitation symptoms 2

For Refractory Symptoms

• Antiarrhythmic medications are reasonable when beta blockers and calcium channel blockers are ineffective or not tolerated 2
• Catheter ablation is useful for symptomatic outflow tract PVCs when medications fail, are not tolerated, or not preferred by the patient 2

For Very Frequent PVCs (>15% burden)

• Catheter ablation is useful when declining ventricular function is suspected due to frequent PVCs and medications are ineffective, not tolerated, or not preferred 2
• Pharmacologic treatment with beta blockers or amiodarone is reasonable to reduce arrhythmias and improve LV function in PVC-induced cardiomyopathy 2

Key Clinical Pitfall

The most important caveat is recognizing that "asymptomatic" patients may actually have subtle symptoms they've attributed to other causes (fatigue, reduced exercise tolerance) - particularly when PVC burden exceeds 10% 6. A careful symptom assessment is essential before labeling PVCs as truly benign.