What is the appropriate work‑up and management for a 49‑year‑old man with a 10‑day history of atypical indigestion‑like chest discomfort, new premature ventricular complexes (PVCs) on electrocardiogram, incomplete right bundle‑branch block, hyperlipidemia, dyspepsia pending Helicobacter pylori urea breath test, a symptomatic umbilical hernia post‑appendectomy, and fatty liver with early portal hypertension on ultrasound, given normal complete blood count, comprehensive metabolic panel, hemoglobin A1c, and thyroid studies?

Management of 49-Year-Old Male with Frequent PVCs, Atypical Chest Pain, and Fatty Liver with Portal Hypertension

Immediate Cardiology Evaluation and PVC Assessment

Given the new frequent PVCs on ECG and incomplete right bundle branch block, this patient requires urgent cardiology evaluation with echocardiography to assess for PVC-induced cardiomyopathy, as frequent PVCs (>10% of total beats) are strongly associated with left ventricular dysfunction. 1, 2

Critical PVC Burden Quantification

• Order 24-hour Holter monitoring immediately to quantify exact PVC burden, as patients with >10% PVC burden have significantly increased risk of cardiomyopathy (37% prevalence of reduced LVEF in one cohort). 2
• PVC burden >20-24% of total beats carries particularly high risk for developing left ventricular dysfunction and requires aggressive management. 3, 4
• The inverse correlation between PVC burden and ejection fraction (r = 0.73) means higher PVC frequency predicts worse cardiac function. 2

Echocardiographic Evaluation

• Obtain transthoracic echocardiography within 1 week to assess left ventricular ejection fraction, chamber dimensions, and exclude structural heart disease. 1, 3
• Look specifically for: LV dilation (end-diastolic dimension >55mm), reduced LVEF (<50%), regional wall motion abnormalities suggesting ischemia, and valvular abnormalities. 2, 5
• If LVEF is reduced, this may represent PVC-induced cardiomyopathy that is potentially reversible with catheter ablation. 2, 5

Exercise Stress Testing

• Perform exercise treadmill test to assess for exercise-induced ventricular arrhythmias and evaluate whether PVCs suppress or increase with exertion. 1
• PVCs that suppress with exercise and occur only at rest are generally benign and do not require aggressive intervention. 1
• PVCs that increase with exercise or convert to non-sustained ventricular tachycardia warrant further evaluation and possible intervention. 1

Cardiac Ischemia Evaluation

Risk Stratification for Acute Coronary Syndrome

• The 10-day history of chest discomfort with dyspeptic features makes acute MI less likely, but incomplete RBBB with chest symptoms requires troponin measurement to exclude NSTE-ACS. 1
• Obtain high-sensitivity troponin at this visit—do not delay if clinical suspicion exists, though the subacute presentation (10 days) makes acute coronary occlusion unlikely. 6, 7
• Compare current ECG with prior ECG from previous presentation to determine if RBBB is truly unchanged or if there are new conduction abnormalities. 1, 7

Coronary Angiography Indications

• If troponin is elevated or if stress test shows ischemia, proceed to coronary angiography given hyperlipidemia and cardiac risk factors. 1, 8
• The combination of chest symptoms, new PVCs, and incomplete RBBB warrants definitive exclusion of coronary artery disease. 1, 6

Management of Frequent PVCs

First-Line Treatment Options

If PVC burden is >10% and/or LVEF is reduced, offer either medical therapy or catheter ablation as first-line treatment based on patient preference. 3, 9

Medical Therapy Approach

• Start beta-blocker therapy (metoprolol succinate 25-50mg daily or carvedilol 3.125-6.25mg twice daily) if LVEF is normal and patient prefers medication. 1, 3
• Non-dihydropyridine calcium channel blockers (diltiazem or verapamil) are alternative first-line agents if beta-blockers are contraindicated. 3, 9
• Avoid class IC antiarrhythmics (flecainide, propafenone) until structural heart disease is definitively excluded by echocardiography and stress testing. 1, 3
• Amiodarone should be reserved for refractory cases given toxicity profile, though it is effective for PVC suppression. 1

Catheter Ablation Approach

• Catheter ablation is the most efficacious therapy for PVC elimination with success rates of 70-90% for outflow tract PVCs. 2, 3
• Ablation should be strongly considered if: PVC burden >20%, LVEF is reduced, or symptoms persist despite medical therapy. 2, 5, 9
• If PVC-induced cardiomyopathy is present, LVEF normalizes in 82% of patients within 6 months after successful ablation. 2
• Right ventricular outflow tract (RVOT) origin PVCs (most common site, 52% of cases) have highest ablation success rates. 2

Monitoring Strategy if Conservative Management Chosen

• Repeat echocardiography in 6 months if PVC burden is <10%, LVEF is normal, and symptoms are minimal. 3, 9
• Continue 24-hour Holter monitoring every 6-12 months to track PVC burden trends. 3
• If LVEF declines or PVC burden increases, proceed immediately to ablation as delayed intervention may result in irreversible cardiomyopathy. 2, 5

Gastrointestinal and Hepatic Management

H. Pylori Testing and Dyspepsia

• Proceed with scheduled H. pylori breath test as planned—ensure patient is fasting and has not taken proton pump inhibitors for 2 weeks prior. 1
• If H. pylori positive, treat with standard triple therapy (PPI + amoxicillin + clarithromycin) for 14 days. 1
• Continue dietary modifications: avoid carbonated beverages, caffeine, alcohol, fatty foods, and large meals. 1

Fatty Liver and Portal Hypertension Evaluation

• The finding of fatty liver with portal vein diameter 1.4cm (normal <1.3cm) suggests early portal hypertension and requires hepatology referral. 1
• Order complete hepatic function panel including: AST, ALT, alkaline phosphatase, total/direct bilirubin, albumin, PT/INR, and hepatitis serologies (A, B, C). 1
• Check fasting lipid panel (already ordered), hemoglobin A1c (already done), and consider metabolic syndrome workup. 1
• Refer to hepatology for evaluation of non-alcoholic fatty liver disease (NAFLD) and possible non-alcoholic steatohepatitis (NASH). 1
• Consider liver elastography (FibroScan) to assess degree of fibrosis non-invasively. 1
• Screen for esophageal varices with upper endoscopy if portal hypertension is confirmed by hepatology. 1

Lifestyle Modifications for Fatty Liver

• Weight loss of 7-10% body weight is the most effective intervention for NAFLD/NASH. 1
• Eliminate alcohol consumption completely. 1
• Optimize diabetes control (check A1c result from recent labs). 1
• Treat hyperlipidemia aggressively—review lipid panel results and consider statin therapy if not already prescribed. 1

Umbilical Hernia Management

Surgical Referral Decision

• Review abdominal ultrasound results to determine hernia size, presence of incarcerated contents, and bowel involvement. 1
• Refer to general surgery for elective hernia repair if hernia is symptomatic (pain, discomfort) or enlarging. 1
• Surgical repair should be scheduled after cardiac evaluation is complete and patient is medically optimized. 1
• Continue to avoid heavy lifting (>10-15 pounds) until surgical evaluation. 1
• If hernia becomes painful, firm, or irreducible, or if patient develops nausea/vomiting, send immediately to emergency department for evaluation of incarceration/strangulation. 1

Critical Pitfalls to Avoid

• Do not assume frequent PVCs are benign without quantifying burden and assessing LV function—PVC-induced cardiomyopathy is reversible if caught early but may become irreversible if left untreated. 2, 5
• Do not use class IC antiarrhythmics (flecainide, propafenone) before excluding structural heart disease—these drugs increase mortality in patients with coronary disease or cardiomyopathy. 1, 3
• Do not dismiss portal hypertension finding—even mild elevation in portal vein diameter requires hepatology evaluation as it may progress to cirrhosis. 1
• Do not delay cardiology referral—the combination of new PVCs, incomplete RBBB, and chest symptoms requires urgent evaluation within 1-2 weeks. 1, 6
• Do not perform stress testing if patient develops acute chest pain with ECG changes—this would be dangerous and contraindicated. 8

Follow-Up Timeline

• Cardiology appointment: within 1-2 weeks for PVC evaluation and risk stratification. 1
• 24-hour Holter monitor: within 1 week to quantify PVC burden. 3
• Echocardiography: within 1 week to assess LV function. 1, 3
• Hepatology referral: within 4-6 weeks for fatty liver and portal hypertension evaluation. 1
• General surgery referral: within 4-8 weeks for hernia evaluation (non-urgent unless symptoms worsen). 1
• Return to primary care in 2 weeks to review all test results and coordinate subspecialty care. 1