From the Guidelines
For asymptomatic premature ventricular contractions (PVCs) in the emergency department, no specific treatment is typically required. Patients with asymptomatic PVCs who are otherwise hemodynamically stable can be discharged with outpatient follow-up. The emergency physician should focus on ruling out underlying causes such as electrolyte abnormalities (particularly hypokalemia, hypomagnesemia), hypoxia, medication effects, or structural heart disease. Basic laboratory tests including electrolytes, cardiac enzymes, and an ECG should be performed. If the patient has risk factors for cardiac disease or frequent PVCs, consider obtaining an echocardiogram either in the ED or as an outpatient. Reassurance is important, as isolated PVCs in patients without structural heart disease generally have a benign prognosis 1. Patients should be advised to avoid potential triggers such as excessive caffeine, alcohol, and stimulants.
Key Considerations
- If PVCs are very frequent (>10-15% of total beats) or the patient has underlying heart disease, outpatient cardiology follow-up should be arranged for consideration of further monitoring or treatment.
- The presence of multiple PVCs may be a hallmark of underlying heart disease, and further evaluation may be necessary to exclude structural heart disease 1.
- Ablation of asymptomatic PVCs may be considered when the PVCs are very frequent to avoid or treat cardiomyopathy, but this is not typically done in the emergency department setting 1.
Rationale
The management of asymptomatic PVCs in the emergency department is focused on ruling out underlying causes and providing reassurance to the patient. The majority of patients with asymptomatic PVCs can be safely discharged with outpatient follow-up. However, patients with frequent PVCs or underlying heart disease may require further evaluation and treatment. The 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death recommend considering amiodarone or catheter ablation in patients with symptomatic PVCs or NSVT, but do not provide specific guidance on the management of asymptomatic PVCs 1. The 2017 international recommendations for electrocardiographic interpretation in athletes suggest that multiple PVCs may be a hallmark of underlying heart disease, and further evaluation may be necessary to exclude structural heart disease 1. Overall, the management of asymptomatic PVCs in the emergency department should be focused on providing reassurance and ruling out underlying causes, with further evaluation and treatment as needed.
From the Research
Treatment of Asymptomatic PVCs in the Emergency Department
- Patients with asymptomatic PVCs (ASx PVCs) and no underlying heart disease may not require treatment, as the prognosis is generally good 2.
- For patients with ASx PVCs and normal ventricular function, simple reassurance may be sufficient 2.
- However, if the patient has a high PVC burden or underlying structural heart disease, further evaluation and treatment may be necessary 3.
Diagnostic Evaluation
- A 12-lead ECG, physical examination, and medical history are essential for diagnosing and evaluating PVCs 2, 3.
- Ambulatory monitoring may be required to assess PVC frequency and burden 2, 3.
- Echocardiography and cardiac magnetic resonance imaging may be indicated in patients with symptoms or high PVC burden to evaluate for underlying structural heart disease 2, 3.
Treatment Options
- For patients with symptomatic PVCs or reduced left ventricular ejection fraction, medical treatment or catheter ablation may be considered as first-line therapies 2.
- Medical treatment options include β-blockers or nondihydropyridine calcium channel blockers for patients with normal ventricular systolic function 2.
- Class I or III antiarrhythmic drugs may be considered for patients who do not respond to initial treatment or have a high PVC burden 4.
- Catheter ablation is a highly effective treatment option for eradicating PVCs, but may confer increased upfront risks 2, 3.