Benign PVCs: A heart rhythm doctor’s approach.

Here is an edited email I received from an athletic colleague:

John,

Quick question….

A 50 year-old male healthy athlete has the new problem of occasional periods of premature beats. He (or she, it doesn’t matter) has visited the doctor and an ECG shows PVCs, or premature ventricular contractions. Otherwise the history, exam, ECG, ECHO and electrolytes are normal.

What’s up with PVCs? Why? Could they be 1) consequence of (chronic) exercise or 2) related in some way to overtraining.

Any thoughts?

PVCs are probably the second most common rhythm problem I see. Atrial arrhythmia, including AF and atrial flutter are the most common.

This image shows PVCs (beats 2, 4, 6 etc) occurring in what we call a bigeminal pattern. Atrial or ventricular beats that appear in an every other beat pattern are referred to as bigeminy. Dr. Fisch called it “boom-boom-pause.”

PVCs

Here are six bullet points on PVCs: (No doubt, if you wanted to be an engineer about it, there would be many more. But then you might indeed get PVCs.)

1. There is an old rule–it’s called the rule of bigeminy. Basically, the long-short intervals of PVCs tend to promote themselves. The point is that PVCs often occur in a bigeminal pattern. It’s not unusual.

2. Understanding PVCs is harder than understanding cyclists. If I had only one adjective for PVCs, I would use capricious. We can’t often find a reason why PVCs come, why they leave, or why they come back.

3. It is worth quantifying facts about the PVCs:

  • Response to exercise: PVCs that mostly occur at times of rest and suppress with exercise are usually benign. PVCs that worsen with exercise may be indicative of a heart under stress, say from a partial blockage of an artery or something else. A heart doctor should evaluate arrhythmia that gets worse with exercise.
  • Quantity of PVCs: A 24-hour-holter monitor tells us how many PVCs occur on a given day. The normal person has about 100,000 heartbeats per day (athletes a few fewer). Patients with more than 20,000 PVCs per day are at risk for developing cardiomyopathy (weak heart). These patients should be referred to an electrophysiologist.

4. In an overwhelming majority of patients, especially those with a structurally normal heart, PVCs are benign. The word benign means the extra beats do not indicate heart disease or predict sudden demise.

5. Mandrola observations: PVCs might indicate training excess. I see this often in athletes. It might happen during a big training block or immediately afterwards. Of course, my theory is that PVCs associate with excess inflammation. The reason I see inflammation as the link is because PVCs often occur in patients who are exposed to stress. The middle-aged person going through a divorce, the doctor embroiled in a lawsuit, the minister who takes care of everyone but himself, the grad student during exams. The theme here is that PVCs tend to cluster at times of high inflammation–be it physical, mental or emotional. But not always.

Recently, a cycling friend told me his PVCs had resolved almost as soon as he stopped training for races. He still rides, fast at times, but doesn’t ‘train.’ (I’m not advocating not racing; it’s just an anecdote.)

6. Ten treatment steps: The first step is to ask what company does the PVC keep? PVCs occurring in patients with a normal heart (by history, exam, ECG and ECHO) are almost always benign.

  • Treatment steps 1-4 are reassurance. It is important to understand the problem, and its benign nature. Removing fear is always a good first step.
  • Steps 5-8 include adjustment of lifestyle, both on a micro and macro style. This gets me back to the 4 legs of the table of health: good food, good exercise, good sleep and good attitude. Cutting back on caffeine and alcohol, looking critically at the dose of exercise, going to bed on time, and smiling are all great strategies for PVCs.
  • Step 9 involves Buddhism. One must know that PVCs are impermanent. Right understanding of PVCs means knowing they will pass.
  • Step 10 involves medicine. I hate when it gets to this step. Beta-blockers are my first choice. These drugs block adrenaline. They sometimes lessen the thudding associated with the irregular beats. Beta-blockers are also good for as-needed use, say for bad days when the PVCs are acting up. And the best part of using beta-blockers: lack of harm. Rarely do I use an anti-arrhythmic drug, like Flecainide or Propafenone or Sotalol.
  • Step 10 (a): Please don’t beat me up on this one. Some patients report benefit from magnesium supplementation. I have found it helpful in my case of atrial premature beats. Let me repeat, I am not promoting supplements. Healthy patients with benign arrhythmia might try taking magnesium, especially at night. Don’t take magnesium if you have kidney disease. And if you take too much, watch out for diarrhea.

Conclusions:

Don’t try too hard to understand PVCs. A basic medical evaluation can exclude significant structural heart disease. Talk to your doctor. Come to a shared decision about what to do.

I am sorry you have them.

JMM

P.S. Please don’t email me or comment with personal medical information. Arrhythmia cannot be treated on the Internet. This post, like all my posts on medical topics, are meant as general guides, not medical advice.

Comments

  1. says

    Nice summary and perspective on PVCs from Dr. John (our expert electrophysiologist). A few additional points:

    i) PVCs may also be precipitated by other “extracardiac” factors in addition to stress, caffeine, alcohol. These include other substances (sympathomimetics, including otc cough-cold preparations and diet pills; meds for ADHD; cocaine; certain herbal preparations … ). Also electrolyte imbalance (low K+/low Mg++); ischemia; heart failure; dehydration; pulmonary disease (hypoxemia); and other significant medical disorder … – may also cause/exacerbate occurrence/frequency of PVCs.

    ii) It is great when you can identify one or more of the factors in i) – because stopping this may reduce/eliminate the PVCs ….

    iii) There is great variability in patient awareness of PVCs. Some patients are totally unaware that they are having many PVCs (even runs) throughout the day. Others may be aware of each and every PVC that they have (they can tell you their first PVC occurred at 9:04 am – and their 2nd PVC of the day came 8 minutes and 15 seconds later). This is why Dr. John recommends reassurance for Steps #1-thru-4 for those patients with benign PVCs who are highly aware of them.

    GREAT post John!

    • says

      Great additions. Absolutely correct, especially about the decongestants. I see that one a lot.

      Also, you are exactly right about perception of PVCs. As in AF, some patients feel the irregular rhythm and some do not. Some feel a little uneasy and some feel horrible.

  2. says

    Timely article!

    I had an acquaintance approach me about their “PVCs” last week. They had the unfortunate experience of receiving a pre-procedure ECG which showed one instance of couplet PVCs. Even though they were completely asymptomatic, serial ECG’s were run without anything interesting, and they were referred to the ED due to their “serious condition”. They weren’t able to receive the procedure until a cardiologist cleared them…

    I think far too often steps 1-4 and 9 are forgotten about! Clinical context can tell a lot about a PVC.

    • says

      Thanks Christopher. Your example captures the essence of at least one of the problems with US healthcare–over-testing.

      Heart rhythm matters scare people, caregivers included. Why would they be scared of an asymptomatic PVC? Because they had forgotten the message about them in training; because EP/Cardiology don’t do enough teaching; because they don’t trust the history and physical, which will confirm the benign nature of the extra beat, and probably because they don’t understand the evidence behind pre-op evaluation. What they do understand is that it costs them nothing to order more tests. Voila…this is US healthcare.

      This is why I like the Choosing Wisely Campaign.

  3. Joe says

    Really nice post, but not even a mention of ablation? What about RVOT PVCs?

    I’m not a huge advocate for this, but I’ve had some patients that feel much better afterwards.

  4. Verted says

    Yes, thank you very much to John and the other responders for an informative discussion.

  5. Cliff says

    Dr John,

    Thanks for the post; I especially like no. 9.

    What about PVCs (or PAC’s) in the years after an ablation for AF? They can be Really Bothersome, and especially when you lose sleep and then go down the road of failing to do 1, 2 or even 3 of the four table-legs. When you’ve lived with a bad symptomatic AF for years then had it fixed (as I and a number of friends have), PVCs/PACs, even when our EP says they’re benign (or at least, not worth/possible doing anything about them) always carry with them the memory and worry of the bad times, also the thought that one of them might just kick the AF off again.

    Thanks in advance

  6. kathie says

    Do you do electrocardiographic imaging (ECGI) before PVI ablation? If not, do your recommend a doctor who does in Louisville? Thank you very much.

  7. Jeff says

    I’m with Cliff.

    I’m told by my electrophysiologist that PVCs and PACs in greater number than “normal” are an artifact of the injury that isolates the pulmonary veins in ablation and are “benign” – not to worry. Well, we worry. Is it true? This odd dancing around in our chests is, for most of us (statistically!), what preceded the dread fibrillations. Cause? Trigger? Natural progression? Will the post ablation PACs truly NOT lead to further fibrillations? It’s a fear that hangs over us and, therefore, deserves being addressed, whether it’s honestly understood by the electrophysiology community or not. Consequent quality-of-life is not unimportant.

    I trust, Dr John, that you’ll see the question of PACs and PVCs as related to ablation and subsequent QOL as general in nature, not personal.

    Thank you.