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PVCS - The good, bad and the ugly

Raja Selvaraj
Professor of Cardiology
JIPMER

Common OPD referral

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PVCs on ECG

  • The Good
    • Common
    • Mostly benign
  • The Bad
    • Can cause symptoms
    • Can be difficult to manage medically
  • The Ugly
    • Can indicate structural heart disease
    • Can lead to LV dysfunction

Questions to ask yourself

  • Is there a possibility of structural heart disease ?
  • Is the patient symptomatic ?
  • Is there LV dysfunction even without structural heart disease ?

Should structural heart disease be suspected ? - PVC

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Should structural heart disease be suspected ? - Sinus beats

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Further evaluation

  • Suspicion of structural heart disease - CMR, PET-CT
  • No suspicion of structural heart disease - Long term ECG recording

Holter - What to look at

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Holter - Interpretation depends on setting

  • Asymptomatic patient
    • Burden determines follow up
  • Symptomatic patient
    • Correlation with symptoms
  • Patient with LV dysfunction
    • Burden determines possibility of PVC induced cardiomyopathy
    • Burden / NSVT may have prognostic value

Scenario 1 - Asymptomatic patient, Idiopathic PVCs, 5% vs 20% on Holter

  • Asymptomatic and infrequent PVCs - No treatment, no periodic re-evaluation
  • Asymptomatic, normal LV function and frequent PVCs - Periodic re-evaluation
  • Ablation because of risk of developing LV dysfunction ? (ESC IIb)

PVCs - Natural history

  • 100 patients with PVCs > 5%
  • PVC resolution to <1% - 44% at median of 15 months
  • Reduction in LVEF (<50%) - 4 patients at median of 60 months

Lee AKY, Andrade J, Hawkins NM, et al. Outcomes of untreated frequent premature ventricular complexes with normal left ventricular function. Heart 2019;105:1408-1413.

Scenario 2 - Symptomatic patient, PVCs related to symptoms

  • Drug therapy - Beta blocker or non-dihydropyridine CCB (AHA Class I)
  • Class Ic in absence of structural heart disease
  • Ablation can be considered first line (ESC class I)
  1. Al-Khatib SM, et al. 2017 AHA/ACC/HRS Guideline on Ventricular Arrhythmias and SCD Prevention. Circulation 2018;138:e272-91.
  2. Zeppenfeld K, et al. 2022 ESC Guideline on Ventricular Arrhythmias and SCD Prevention. Eur Heart J 2022;43:3997-4126.

Scenario 3 - LV dysfunction, 5% vs 20% PVCs on Holter

  • Low PVC load - treatment for LV dysfunction alone
  • High PVC load - Possibility of PVC induced / worsened cardiomyopathy - treat PVCs

PVC burden

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Penela D et al. Clinical recognition of pure premature ventricular complex-induced cardiomyopathy at presentation. Heart Rhythm. 2017 Dec;14(12):1864-1870. doi: 10.1016/j.hrthm.2017.07.025.

Ablation is very effective for PVCs

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Calvo N, Jongbloed M, Zeppenfeld K. Radiofrequency catheter ablation of idiopathic right ventricular outflow tract arrhythmias. Indian Pacing Electrophysiol J. 2013 Jan;13(1):14-33. doi: 10.1016/s0972-6292(16)30585-x.

Summary - Evaluation and management of patient with PVCs

  • Occult heart disease ?
  • Symptoms ? - Needs treatment
  • Asymptomatic, but high load and LV dysfunction - Needs treatment
  • Asymptomatic and normal LV function - Needs only follow up