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Premature Ventricular Contraction Clinical Presentation

  • Author: James E Keany, MD, FACEP; Chief Editor: Erik D Schraga, MD  more...
 
Updated: Dec 07, 2015
 

History

The important elements in obtaining a history from patients with ventricular ectopy are a history of cardiac disease or structural heart disease. Current medications that may be proarrhythmic or that may increase the risk of abnormal potassium or magnesium levels and use of drugs or medications that are sympathomimetic (eg, ephedrine-containing products, cocaine), may also provide important clues to the source of the premature ventricular contractions (PVCs).

Symptoms pertinent to the management of the PVCs are those that suggest underlying ischemic cardiac disease, such as chest pain or its anginal equivalent, or those suggesting hemodynamic compromise, such as lightheadedness or syncope. Note the following:

  • Patients are usually asymptomatic.
  • Cannon A waves or the increased force of contraction due to postextrasystolic potentiation of contractility can cause palpitations and neck and/or chest discomfort.
  • The patient may report feeling that his or her heart "stops" after a PVC.
  • Patients with frequent PVCs or bigeminy may report syncope. This symptom is due to either inadequate stroke volume or decreased cardiac output caused by the condition effectively halving the heart rate.
  • Long runs of PVCs can result in hypotension.
  • Exercise can increase or decrease the PVC rate.
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Physical Examination

Important findings on the physical examination are those that provide clues to the underlying cause of the ventricular ectopy, including the following:

  • Blood pressure: Frequent premature ventricular contractions (PVCs) may result in hemodynamic compromise. Frank hypotension is rare, but relative hypotension is not uncommon, particularly in patients with underlying cardiac disease.
  • Pulse: The ectopic beat may produce a diminished or absent pulse depending on the force of the ventricular contraction.
  • Pulse oximetry: Hypoxia may precipitate PVCs.
  • Cardiac findings: Cannon A waves may be observed in the jugular venous pulse if the timing of the PVC causes an atrial contraction against a closed tricuspid valve.
  • Cardiopulmonary findings: Findings in conjunction with longstanding hypertension (elevated BP and an S 4 ) or CHF (S 3 and rales) are important clues to the cause and clinical significance of PVCs.
  • Neurologic findings: Agitation and findings of sympathetic activation (eg, dilated pupils, warm and dry skin, tremor, tachycardia, hypertension) suggest that catecholamines may be the cause of the ectopy.
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Contributor Information and Disclosures
Author

James E Keany, MD, FACEP Associate Medical Director, Emergency Services, Mission Hospital Regional Medical Center, Children's Hospital of Orange County at Mission

James E Keany, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, California Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Aseem D Desai, MD, FACC Cardiac Electrophysiologist, Mission Internal Medicine Group, Inc

Aseem D Desai, MD, FACC is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eddy S Lang, MDCM, CCFP(EM), CSPQ Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary Faculty of Medicine; Assistant Professor, Department of Family Medicine, McGill University Faculty of Medicine, Canada

Eddy S Lang, MDCM, CCFP(EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Canadian Association of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Additional Contributors

Assaad J Sayah, MD, FACEP Chief, Department of Emergency Medicine; Senior Vice President, Primary and Emergency Care, Cambridge Health Alliance

Assaad J Sayah, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, National Association of EMS Physicians

Disclosure: Nothing to disclose.

References
  1. Lee AK, Deyell MW. Premature ventricular contraction-induced cardiomyopathy. Curr Opin Cardiol. 2016 Jan. 31 (1):1-10. [Medline].

  2. Simpson RJ, Cascio WE, Schreiner PJ, et al. Prevalence of premature ventricular contractions in a population of African American and white men and women: the Atherosclerosis Risk in Communities (ARIC) study. Am Heart J. 2002 Mar. 143(3):535-40. [Medline].

  3. CAST Investigators. Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. N Engl J Med. 1989 Aug 10. 321(6):406-12. [Medline].

  4. Lee CH, Park KH, Nam JH, et al. Increased variability of the coupling interval of premature ventricular contractions as a Predictor of cardiac mortality in patients with left ventricular dysfunction. Circ J. 2015 Oct 23. 79 (11):2360-6. [Medline].

  5. Maruyama T, Fukata M. Increased coupling interval variability - mechanistic, diagnostic and prognostic Implication of premature ventricular contractions and underlying heart diseases. Circ J. 2015 Oct 23. 79 (11):2317-9. [Medline].

  6. Agarwal SK, Heiss G, Rautaharju PM, Shahar E, Massing MW, Simpson RJ Jr. Premature ventricular complexes and the risk of incident stroke: the Atherosclerosis Risk In Communities (ARIC) Study. Stroke. 2010 Apr. 41(4):588-93. [Medline].

  7. [Guideline] Aliot EM, Stevenson WG, Almendral-Garrote JM, Bogun F, Calkins CH, Delacretaz E, et al. EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias: developed in a partnership with the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA). Europace. 2009 Jun. 11(6):771-817. [Medline]. [Full Text].

  8. Bala R, Marchlinski FE. Electrocardiographic recognition and ablation of outflow tract ventricular tachycardia. Heart Rhythm. 2007 Mar. 4(3):366-70. [Medline].

  9. Burkart F, Pfisterer M, Kiowski W, et al. Effect of antiarrhythmic therapy on mortality in survivors of myocardial infarction with asymptomatic complex ventricular arrhythmias: Basel Antiarrhythmic Study of Infarct Survival (BASIS). J Am Coll Cardiol. 1990 Dec. 16(7):1711-8. [Medline].

  10. Cairns JA, Connolly SJ, Roberts R, Gent M. Randomised trial of outcome after myocardial infarction in patients with frequent or repetitive ventricular premature depolarisations: CAMIAT. Canadian Amiodarone Myocardial Infarction Arrhythmia Trial Investigators. Lancet. 1997 Mar 8. 349(9053):675-82. [Medline].

  11. Califf RM, McKinnis RA, Burks J, et al. Prognostic implications of ventricular arrhythmias during 24 hour ambulatory monitoring in patients undergoing cardiac catheterization for coronary artery disease. Am J Cardiol. 1982. 50:23-31. [Medline].

  12. Cha YM, Lee GK, Klarich KW, Grogan M. Premature ventricular contraction-induced cardiomyopathy: a treatable condition. Circ Arrhythm Electrophysiol. 2012 Feb 1. 5(1):229-36. [Medline].

  13. Del Gobbo LC, Song Y, Poirier P, Dewailly E, Elin RJ, Egeland GM. Low serum magnesium concentrations are associated with a high prevalence of premature ventricular complexes in obese adults with type 2 diabetes. Cardiovasc Diabetol. 2012 Mar 9. 11(1):23. [Medline].

  14. Hallstrom AP, Bigger JT Jr, Roden D, et al. Prognostic significance of ventricular premature depolarizations measured 1 year after myocardial infarction in patients with early postinfarction asymptomatic ventricular arrhythmia. J Am Coll Cardiol. 1992 Aug. 20(2):259-64. [Medline].

  15. Hammill SC, Trusty JM, Wood DL, et al. Influence of ventricular function and presence or absence of coronary artery disease on results of electrophysiologic testing for asymptomatic nonsustained ventricular tachycardia. Am J Cardiol. 1990 Mar 15. 65(11):722-8. [Medline].

  16. Hargarten K, Chapman PD, Stueven HA, et al. Prehospital prophylactic lidocaine does not favorably affect outcome in patients with chest pain. Ann Emerg Med. 1990 Nov. 19(11):1274-9. [Medline].

  17. Jouven X, Zureik M, Desnos M, et al. Long-term outcome in asymptomatic men with exercise-induced premature ventricular depolarizations. N Engl J Med. 2000 Sep 21. 343(12):826-33. [Medline].

  18. Kennedy HL, Whitlock JA, Sprague MK, et al. Long-term follow-up of asymptomatic healthy subjects with frequent and complex ventricular ectopy. N Engl J Med. 1985 Jan 24. 312(4):193-7. [Medline].

  19. Lown B, Wolf M. Approaches to sudden death from coronary heart disease. Circulation. 1971 Jul. 44(1):130-42. [Medline].

  20. Maggioni AP, Zuanetti G, Franzosi MG, et al. Prevalence and prognostic significance of ventricular arrhythmias after acute myocardial infarction in the fibrinolytic era. GISSI-2 results. Circulation. 1993 Feb. 87(2):312-22. [Medline].

  21. Rehnqvist N, Olsson G, Erhardt L, Ekman AM. Metoprolol in acute myocardial infarction reduces ventricular arrhythmias both in the early stage and after the acute event. Int J Cardiol. 1987 Jun. 15(3):301-8. [Medline].

  22. Teo KK, Yusuf S, Furberg CD. Effects of prophylactic antiarrhythmic drug therapy in acute myocardial infarction. An overview of results from randomized controlled trials. JAMA. 1993 Oct 6. 270(13):1589-95. [Medline].

  23. Yokokawa M, Kim HM, Good E, Chugh A, Pelosi F Jr, Alguire C, et al. Relation of symptoms and symptom duration to premature ventricular complex-induced cardiomyopathy. Heart Rhythm. 2012 Jan. 9(1):92-5. [Medline].

  24. Zamir M, Kimmerly DS, Shoemaker JK. Cardiac mechanoreceptor function implicated during premature ventricular contraction. Auton Neurosci. 2012 Apr 3. 167(1-2):50-5. [Medline].

  25. Zhong L, Lee YH, Huang XM, Asirvatham SJ, Shen WK, Friedman PA. Relative efficacy of catheter ablation vs antiarrhythmic drugs in treating premature ventricular contractions: A single-center retrospective study. Heart Rhythm. 2013 Oct 22. [Medline].

  26. Bradfield JS, Homsi M, Shivkumar K, Miller JM. Coupling interval variability differentiates ventricular ectopic complexes arising in the aortic sinus of valsalva and great cardiac vein from other sources: mechanistic and arrhythmic risk implications. J Am Coll Cardiol. 2014 May 27. 63 (20):2151-8. [Medline].

  27. Trevisi N, Silberbauer J, Radinovic A, et al. New diagnostic criteria for identifying left-sided ventricular ectopy using non-contact mapping and virtual unipolar electrogram analysis. Europace. 2015 Jan. 17 (1):108-16. [Medline].

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ECG shows frequent, unifocal PVCs with a fixed coupling interval between the ectopic beat and the previous beat. These PVCs result in a fully compensatory pause; the interval between the 2 sinus beats surrounding the PVC are exactly twice the normal R-R interval. This finding indicates that the sinus node continues to pace at its normal rhythm despite the PVC, which fails to reset the sinus node.
On this ECG, the PVCs occur near the peak of the T wave of the preceding beat. These beats predispose the patient to ventricular tachycardia or fibrillation. This R-on-T pattern is often seen in patients with acute myocardial infarction or long Q-T intervals. In the latter case, the triggered arrhythmia would be torsade.
 
 
 
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