eMedicine Specialties > Emergency Medicine > Cardiovascular

Premature Ventricular Contraction: Follow-up

Author: James E Keany, MD, FACEP, Medical Director, JetWest International Air Ambulance; Consulting Staff, Department of Emergency Services, Mission Hospital Regional Medical Center; Host of Healthbuzz at Jim.MD
Coauthor(s): Aseem D Desai, MD, FACC, Cardiac Electrophysiologist, Mission Internal Medicine Group, Inc
Contributor Information and Disclosures

Updated: Nov 16, 2009

Follow-up

Further Outpatient Care

  • Catheter ablative therapy has a role in the management of patients with PVCs. This is in the setting of PVCs from the right or left ventricular outflow tract that occur in structurally normal hearts. Ablation is indicated for frequent, symptomatic PVCs despite medical therapy. Success is variable depending on frequency and inducibility at the time of electrophysiologic study. Guidelines on the use of catheter ablation in ventricular arrhythmia are available from the European Heart Rhythm Association (EHRA) and the Heart Rhythm Society (HRS) in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA).2

Prognosis

  • In asymptomatic patients without underlying heart disease, the long-term prognosis is similar to that of the general population. Asymptomatic patients with ejection fractions greater than 40% have a 3.5% incidence of sustained ventricular tachycardia or cardiac arrest. Therefore, in patients with absence of heart disease on noninvasive workup, reassurance is appropriate. One caveat to this is that emerging data suggest that very frequent ventricular ectopy (>4000/24 h) may be associated with the development of cardiomyopathy related to abnormal electrical activation of the heart. This mechanism is thought to be similar to that of chronic right ventricular pacing associated cardiomyopathy.
  • In the setting of acute coronary ischemia/infarction, patients with simple PVCs rarely progress to malignant arrhythmias. However, persistent complex ectopy after MI is associated with increased risk of sudden death and may be an indication for EPS.
  • Patients with underlying chronic structural heart disease (eg, cardiomyopathy, infarction, valvular disease) and complex ectopy (eg, >10 PVCs/h) have a significantly increased rate of mortality.
    • Understanding of the role of antiarrhythmic therapy in the months after MI is poor. The Cardiac Arrhythmia Suppression Trial (CAST) studied patients with ventricular ectopy after MI to see if antiarrhythmic therapy improved survival rates.3 Despite suppression of ectopy on Holter monitoring, patients treated with encainide, flecainide, or moricizine had increased rates of sudden death and death from all causes. Findings have suggested a role for amiodarone in this patient population and have had significant reductions in rates of post-MI ventricular arrhythmias and death. Moricizine (Ethmozine) was discontinued in July 2007 because of diminished market demand.
    • Left ventricular dysfunction has a stronger association with increased mortality rate than do PVCs. Many now believe that PVCs reflect the severity of heart disease rather than contribute to arrhythmogenesis.
    • EPS has a primary role in risk stratification of patients with frequent or complex PVCs. Patients with PVCs that are noninducible (ie, unable to trigger ventricular tachycardia during stimulation) have a low risk of sudden death.

Miscellaneous

Special Concerns

  • Children
    • PVCs are less common in children than in adults, but PVCs do occur in healthy children.
    • About 20% of healthy boys aged 10-13 years have PVCs on routine Holter monitoring.
    • PVCs in healthy newborns generally resolve by the 12th week and usually require no treatment once the presence of a healthy heart is confirmed. This finding probably is related to developmental factors associated with the autonomic nervous system.
    • In older children, PVCs often are related to transient or exogenous factors, including mild viral myocarditis, excessive caffeine, or sympathomimetic drugs (cold or asthma medications). They usually resolve without treatment.
  • When complex ectopy is seen in pregnancy, or immediately after, obtain an ECG for possible peripartum cardiomyopathy.
  • Closely monitor and admit to an appropriate monitored setting patients with presentations that indicate an ischemic basis for their PVCs (eg, chest pain, dyspnea, syncope) or who are hemodynamically unstable while in the ED.
 


More on Premature Ventricular Contraction

Overview: Premature Ventricular Contraction
Differential Diagnoses & Workup: Premature Ventricular Contraction
Treatment & Medication: Premature Ventricular Contraction
Follow-up: Premature Ventricular Contraction
Multimedia: Premature Ventricular Contraction
References
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References

  1. 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. Mar 2002;143(3):535-40. [Medline].

  2. [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. Jun 2009;11(6):771-817. [Medline]. [Full Text].

  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. Aug 10 1989;321(6):406-12. [Medline].

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

  5. 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. Dec 1990;16(7):1711-8. [Medline].

  6. 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. Mar 8 1997;349(9053):675-82. [Medline].

  7. 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].

  8. 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. Aug 1992;20(2):259-64. [Medline].

  9. 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. Mar 15 1990;65(11):722-8. [Medline].

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

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

  12. 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. Jan 24 1985;312(4):193-7. [Medline].

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

  14. 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. Feb 1993;87(2):312-22. [Medline].

  15. 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. Jun 1987;15(3):301-8. [Medline].

  16. 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. Oct 6 1993;270(13):1589-95. [Medline].

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Further Reading

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Keywords

premature ventricular contraction, premature ventricular contraction causes, premature ventricular contraction treatment, PVC, ectopic cardiac pacemaker, paroxysmal tachycardia, arrhythmias, dysrhythmias, acute myocardial infarction, MI, ventricular ectopy, myocarditis, dilated cardiomyopathy, hypertrophic cardiomyopathy

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Contributor Information and Disclosures

Author

James E Keany, MD, FACEP, Medical Director, JetWest International Air Ambulance; Consulting Staff, Department of Emergency Services, Mission Hospital Regional Medical Center; Host of Healthbuzz at Jim.MD
James E Keany, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, and 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, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Assaad J Sayah, MD, Chief, Department of Emergency Medicine, Cambridge Health Alliance
Assaad J Sayah, MD is a member of the following medical societies: National Association of EMS Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eddy Lang, MDCM, CCFP (EM), CSPQ, Assistant Professor, Department of Family Medicine, McGill University; Consulting Staff, Department of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Eddy Lang, MDCM, CCFP (EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD, Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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