From the Guidelines
A referral to cardiology is recommended for frequent premature ventricular contractions (PVCs) and non-sustained ventricular tachycardia (VTac) due to the potential association with underlying heart disease and increased risk of adverse cardiovascular outcomes. According to the 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1, 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. Additionally, nonsustained ventricular tachycardia (NSVT) is independently associated with increased risk of death and other cardiovascular adverse outcomes, including stroke 1.
The evaluation of patients with frequent PVCs and NSVT should include a comprehensive assessment, such as an electrocardiogram (ECG), echocardiogram to evaluate heart structure and function, and possibly a 24-48 hour Holter monitor or longer-term event recorder to quantify arrhythmia burden, as recommended by the European Heart Rhythm Association (EHRA) and ESC Council on Hypertension 1. If PVCs exceed 10-15% of total heartbeats or if non-sustained VTac episodes are frequent or symptomatic, treatment may be necessary, and management options might include beta-blockers like metoprolol or calcium channel blockers such as verapamil.
While awaiting the cardiology appointment, it's advisable to avoid excessive caffeine, alcohol, and stimulants which can trigger arrhythmias, as suggested by the EHRA and ESC Council on Hypertension 1. These arrhythmias warrant evaluation because they can sometimes be associated with structural heart disease, cardiomyopathy, or in rare cases, may progress to sustained ventricular arrhythmias with hemodynamic compromise. Key considerations in the management of these patients include:
- A thorough clinical history and examination
- Blood chemistry and a 12-lead ECG
- A 24-h Holter recording
- Transthoracic echocardiography to assess for signs of hypertensive or structural heart disease
- Investigation for reversible, secondary causes of increased ventricular ectopy, such as electrolyte imbalances or thyroid disorders.
From the Research
Referral to Cardiology for Frequent PVCs and Non-Sustained VTac
- 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.
- Medical therapy, including beta-blockers and class III anti-arrhythmic agents, can be effective in managing PVCs and NSVT, while implantable cardiac defibrillators (ICD) are indicated in certain patients 2.
- Radiofrequency ablation (RFA) is a preferred, definitive treatment for patients who improve with anti-arrhythmic therapy, have tachycardia-induced cardiomyopathy, or have certain subtypes of PVCs/NSVT 2, 3.
- The combination of verapamil and flecainide may be a useful treatment option for ventricular arrhythmias in patients with RYR1-related myopathies 4.
- Evaluation and management of PVCs involve history, physical examination, 12-lead ECG, echocardiogram, and ambulatory monitoring, with treatment options including medical therapy, catheter ablation, or a combination of both 5.
Indications for Referral
- Symptoms such as palpitations, dyspnea, presyncope, and fatigue associated with PVCs or NSVT 5.
- Frequent PVCs or NSVT, particularly in patients with underlying cardiac disease or structural heart disease 2, 5.
- Presence of systolic dysfunction or reduced left ventricular ejection fraction 5.
- Failure of medical treatment or decline of catheter ablation 5.