What is the next measure for a patient with a history of Hypertension (HTN) on Metoprolol (metoprolol) Succinate 100 mg daily, experiencing palpitations with occasional Premature Ventricular Contractions (PVCs) and 2 episodes of Non-Sustained Ventricular Tachycardia (NSVT) on Holter monitoring?

From the Guidelines

For a patient with hypertension on metoprolol succinate 100 mg daily who is experiencing palpitations with documented occasional premature ventricular contractions (PVCs) and two episodes of non-sustained ventricular tachycardia (NSVT) on Holter monitoring, the next appropriate measure would be to consider catheter ablation or amiodarone, as these options are recommended for patients with frequent symptomatic PVC or NSVT, according to the 2015 ESC guidelines 1.

When evaluating this patient, it's crucial to consider the potential impact of PVCs and NSVT on left ventricular function, as these arrhythmias can contribute to or be a consequence of left ventricular dysfunction 1. The presence of more than 10 PVCs per hour or runs of NSVT can be an acceptable marker of increased risk, and in symptomatic patients, treatment should be considered to prevent further deterioration of cardiac function.

Given the patient's symptoms and Holter findings, the following steps should be taken:

• Refer the patient for a comprehensive cardiac evaluation, including an echocardiogram to assess for structural heart disease and left ventricular function.
• Order laboratory tests to check electrolytes, thyroid function, and rule out other metabolic causes of arrhythmias.
• Consider optimizing the dose of metoprolol if the current dose is not controlling symptoms, as beta-blockers are a first-line treatment for PVCs and NSVT.
• If symptoms persist, consider referral to an electrophysiologist for possible electrophysiology study and consideration of antiarrhythmic medications like amiodarone or catheter ablation, as recommended by the 2015 ESC guidelines for patients with frequent symptomatic PVC or NSVT 1.

It's essential to prioritize the patient's symptoms and cardiac function when deciding on the next course of action, as the goal is to improve morbidity, mortality, and quality of life. The 2015 ESC guidelines provide a framework for managing patients with ventricular arrhythmias, and in this case, considering catheter ablation or amiodarone is a reasonable next step 1.

From the Research

Next Measures for Patient with Palpitations and PVCs

The patient's symptoms of palpitations and occasional PVCs with 2 episodes of NSVT, as shown on the Holter monitor, require further evaluation and management.

• The patient is already on metoprolol succinate 100 mg daily for hypertension, which is a beta-blocker that can be used to treat arrhythmias 2, 3.
• The use of ambulatory electrocardiographic (ECG) monitoring, such as a Holter monitor, is appropriate for patients with palpitations, especially when the etiology cannot be determined from the patient's history, physical examination, and resting ECG 4, 5.
• Given the patient's symptoms and Holter monitor results, the next measure would be to assess the patient's response to the current beta-blocker therapy and consider adjusting the dose or adding other medications as needed to control the arrhythmias 2, 3.
• It is also important to identify and manage any underlying conditions that may be contributing to the patient's palpitations, such as hypertension, and to monitor the patient for any signs of more serious arrhythmias or cardiac conditions 4, 5, 6.
• The patient's treatment and follow-up will depend on the underlying cause of the palpitations and the results of further evaluation and monitoring 5.