From the Guidelines
A regular PVC every fifth beat, also known as quadrigeminy, is typically benign in patients without structural heart disease, but it is crucial to evaluate the patient by a healthcare provider to rule out underlying conditions that may warrant further treatment. This rhythm occurs when an ectopic focus in the ventricles fires prematurely, disrupting the normal heart rhythm, but the predictable pattern of quadrigeminy suggests a stable underlying electrical issue rather than a more concerning arrhythmia 1. According to the 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death, frequent PVCs, defined as the presence of at least 1 PVC on a 12-lead ECG or >30 PVCs per hour, are associated with increased cardiovascular risk and increased mortality 1.
Evaluation and Treatment
The detection of PVCs, particularly if multifocal and frequent, is generally considered a risk factor for adverse cardiovascular outcomes, and such patients are generally evaluated to ensure they do not have underlying conditions (e.g., ischemic heart disease, left ventricular dysfunction) that warrant further treatment to reduce risk 1. For symptomatic patients, beta-blockers like metoprolol (25-100 mg twice daily) or calcium channel blockers such as diltiazem (120-360 mg daily) may be prescribed to reduce symptoms. Lifestyle modifications including reducing caffeine, alcohol, and stress can help decrease PVC frequency. Adequate sleep and staying well-hydrated are also beneficial. If PVCs are frequent (>10-15% of total heartbeats) or associated with symptoms like palpitations, dizziness, or shortness of breath, further cardiac evaluation with an echocardiogram and possibly a stress test is warranted to rule out underlying heart disease.
Considerations for Patients with Structural Heart Disease
In patients with left ventricular dysfunction and premature ventricular complex, catheter ablation should be considered, especially if the patient has a high PVC burden (>24%) and a short coupling interval of the PVCs (<300 ms), as it can suppress PVCs and restore LV function 1. Additionally, amiodarone may be considered for patients with frequent symptomatic PVC or NSVT. It is essential to note that treatment of PVCs with antiarrhythmic medications has not been shown to reduce mortality, and in some cases, may increase the risk of death, particularly in patients with post-myocardial infarction or reduced LVEF 1.
Key Points
- Regular PVC every fifth beat is typically benign in patients without structural heart disease
- Evaluation by a healthcare provider is crucial to rule out underlying conditions
- Beta-blockers or calcium channel blockers may be prescribed for symptomatic patients
- Lifestyle modifications can help decrease PVC frequency
- Further cardiac evaluation is warranted if PVCs are frequent or associated with symptoms
- Catheter ablation may be considered for patients with left ventricular dysfunction and premature ventricular complex.
From the Research
Premature Ventricular Complexes (PVCs)
- PVCs are extremely common, found in the majority of individuals undergoing long-term ambulatory monitoring 2
- Increasing age, a taller height, a higher blood pressure, a history of heart disease, performance of less physical activity, and smoking each predict a greater PVC frequency 2
Diagnosis and Evaluation
- The history, physical examination, and 12-lead ECG are each critical to the diagnosis and evaluation of a PVC 2
- An echocardiogram is indicated in the presence of symptoms or particularly frequent PVCs, and cardiac magnetic resonance imaging is helpful when the evaluation suggests the presence of associated structural heart disease 2
- Ambulatory monitoring is required to assess PVC frequency 2
Treatment
- Patients with no or mild symptoms, a low PVC burden, and normal ventricular function may be best served with simple reassurance 2
- Either medical treatment or catheter ablation are considered first-line therapies in most patients with PVCs associated with symptoms or a reduced left ventricular ejection fraction 2
- β-blockers or nondihydropyridine calcium channel blockers are reasonable drugs in patients with normal ventricular systolic function 2
- Predictors of positive response to beta-blockers for treatment of PVCs include PVC QRS width and positive correlation between hourly heart rate and PVC incidence 3