From the Guidelines
A referral to cardiology is strongly recommended for frequent premature ventricular contractions (PVCs) and non-sustained ventricular tachycardia (NSVT) due to the potential association with underlying heart disease and increased risk of adverse cardiovascular outcomes. According to the 2018 guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1, PVCs are common and increase in frequency with age, but frequent PVCs are associated with increased cardiovascular risk and mortality. The presence of PVCs on 2 minutes of monitoring was associated with increased risk of both ischemic heart disease events and mortality, with or without prevalent ischemic heart disease.
While waiting for the appointment, it's advisable to avoid excessive caffeine, alcohol, and stimulants which can trigger arrhythmias. The cardiologist will likely perform tests including a 12-lead ECG, echocardiogram, and possibly Holter monitoring to assess the frequency and pattern of the arrhythmias, as recommended by the American Heart Association and American College of Cardiology 1. They may also order exercise stress testing or cardiac MRI depending on the specific presentation.
Some key points to consider:
- The detection of PVCs, particularly if multifocal and frequent, is generally considered a risk factor for adverse cardiovascular outcomes 1.
- Treatment of PVCs with antiarrhythmic medications has not been shown to reduce mortality, and in some cases, may increase the risk of death 1.
- Beta blockers, such as metoprolol, may be considered as a treatment option, starting at 25-50mg twice daily.
- For some patients with very frequent PVCs causing symptoms or heart dysfunction, catheter ablation might be considered.
- The urgency of the referral depends on symptoms, with chest pain, syncope, or severe palpitations warranting more immediate evaluation.
From the Research
Referral to Cardiology for Frequent PVCs and Non-Sustained VTEC
- Frequent premature ventricular contractions (PVCs) and non-sustained ventricular tachycardia (NSVT) can be a marker of electrocardiomyopathy and increase the risk for sustained ventricular tachycardia, ventricular fibrillation, and sudden cardiac death 2.
- PVCs are relatively common, occurring in 3%-20% of the general population, and are often found during work-up of palpitations or incidentally on routine electrocardiographic testing 3.
- Referral to cardiology may be necessary for evaluation and management of PVCs and NSVT, especially if symptoms are present or if the PVC burden is high 4.
- The evaluation of PVCs and NSVT includes a history, physical examination, 12-lead ECG, and ambulatory monitoring to assess PVC frequency 4.
- Echocardiogram and cardiac magnetic resonance imaging may be indicated in the presence of symptoms or particularly frequent PVCs to evaluate for associated structural heart disease 4.
- Treatment options for PVCs and NSVT include medical therapy with beta-blockers or class III anti-arrhythmic agents, catheter ablation, and implantable cardiac defibrillators (ICD) in certain patients 2, 4.
- Catheter ablation is a safe and effective curative therapy for PVCs/VT originating from the left ventricular outflow tract (LVOT) and can be considered an effective therapeutic option for patients with frequent ventricular arrhythmias and arrhythmic storm 5, 6.