What are the implications of premature ventricular complexes (PVCs) on an electrocardiogram (ECG)?

From the Guidelines

Premature ventricular complexes (PVCs) on an EKG are associated with increased cardiovascular risk and mortality, particularly if frequent or multifocal, and warrant evaluation to rule out underlying conditions such as ischemic heart disease or left ventricular dysfunction. The presence of PVCs on a 12-lead ECG or more than 30 PVCs per hour is considered a risk factor for adverse cardiovascular outcomes 1. PVCs are common and increase in frequency with age, with approximately 50% of people with or without heart disease experiencing PVCs on longer-term monitoring 1. The detection of PVCs, especially if multifocal and frequent, is generally considered a risk factor for adverse cardiovascular outcomes, and such patients are typically evaluated to ensure they do not have underlying conditions that warrant further treatment to reduce risk 1.

Some key points to consider when evaluating PVCs on an EKG include:

• The frequency and multifocality of PVCs, as these factors are associated with increased cardiovascular risk and mortality 1
• The presence of underlying heart disease, such as ischemic heart disease or left ventricular dysfunction, which may warrant further treatment to reduce risk 1
• The use of antiarrhythmic medications, which has not been shown to reduce mortality and may even increase the risk of death in certain populations, such as post-myocardial infarction patients 1
• The potential benefits of lifestyle modifications, such as reducing caffeine, alcohol, and stress, and medications like beta-blockers or calcium channel blockers, in managing symptomatic patients 1

In terms of management, beta blockers are a recommended treatment option for patients with PVCs, particularly those with underlying heart disease or left ventricular dysfunction. However, the use of antiarrhythmic medications, such as class I sodium channel-blocking medications, is generally not recommended due to the increased risk of death associated with these medications 1. Overall, the approach to managing PVCs on an EKG should prioritize evaluating and addressing underlying conditions, rather than simply suppressing the arrhythmia itself 1.

From the FDA Drug Label

Propafenone causes a dose-related and concentration-related decrease in the rate of single and multiple premature ventricular contractions (PVCs) and can suppress recurrence of ventricular tachycardia

• Key Points:
  • Propafenone decreases the rate of premature ventricular contractions (PVCs)
  • Propafenone can suppress recurrence of ventricular tachycardia
• Clinical Decision: Propafenone may be effective in reducing premature complexes on EKG, specifically premature ventricular contractions (PVCs) 2

From the Research

Premature Complexes on EKG

• Premature ventricular complexes (PVCs) are consistently associated with worse prognosis and higher morbidity and mortality 3.
• PVCs in the structurally normal heart are usually benign, but in the presence of structural heart disease (SHD), they may indicate increased risk of sudden death 4.
• High PVC burden may induce cardiomyopathy and left ventricular (LV) dysfunction or worsen underlying cardiomyopathy 4, 5.
• PVCs are commonly asymptomatic but can also result in palpitations, dyspnea, presyncope, and fatigue 5.
• The history, physical examination, and 12-lead ECG are each critical to the diagnosis and evaluation of a PVC 5.

Diagnostic Procedures

• A 12-lead ECG is used to characterize QRS morphology 3, 5.
• Holter monitor is used to assess frequency of PVCs 3, 5.
• Echocardiogram is indicated in the presence of symptoms or particularly frequent PVCs 5.
• Cardiac magnetic resonance imaging is helpful when the evaluation suggests the presence of associated structural heart disease 5.

Treatment Options

• Watchful waiting, medical therapy, or catheter ablation are options for management of PVCs 3.
• Medical treatment includes β-blockers or nondihydropyridine calcium channel blockers in patients with normal ventricular systolic function 5.
• Catheter ablation is the most efficacious approach to eradicate PVCs but may confer increased upfront risks 5.