Premature Ventricular Contraction Treatment & Management
- Author: James E Keany, MD, FACEP; Chief Editor: Erik D Schraga, MD more...
The optimal indications for therapy have not yet been elucidated. Involvement of a cardiologist may be indicated if the patient's condition is refractory to standard therapy.
Catheter ablative therapy has a role in the management of patients with premature ventricular contractions (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).
Perform telemetry, and secure intravenous (IV) access.
Administer oxygen, if any hypoxia exists.
Complex ectopy in the setting of myocardial ischemia or causing hemodynamic instability should be suppressed. Use lidocaine for patients with myocardial ischemia.
Emergency Department Care
The decision to treat premature ventricular contractions (PVCs) in the emergency or outpatient settings depends on the clinical scenario. In the absence of cardiac disease, isolated, asymptomatic ventricular ectopy, regardless of configuration or frequency, requires no treatment. With cardiac disease, certain toxic effects, and electrolyte imbalances, treatment may be required. Establish telemetry and IV access, initiate oxygen, and obtain a 12-lead ECG.
Note the following:
- Hypoxia: Treat the underlying cause; secure the ABCs and provide oxygen.
- Drug toxicity: Specific therapy is indicated for certain toxic effects. Examples include digoxin (Fab antibodies), tricyclics (bicarbonate), and aminophylline (GI decontamination and possibly hemodialysis).
- Correct electrolyte imbalances, particularly those of magnesium, calcium, and potassium.
Acute ischemia and/or infarction
Early diagnosis and treatment of acute infarction/ischemia are the cornerstones of therapy. Note the following:
- The routine use of lidocaine and other type I antiarrhythmic agents in the setting of acute MI is no longer recommended because of their toxic effects.
- Acute ischemia or infarction includes patients with ectopy in the period immediately after receiving thrombolytic agents, during which complex ectopy frequently is seen.
- First-line therapy for ectopy without hemodynamic significance in patients post-MI is beta-blockade.
- Only in the setting of symptomatic, complex ectopy is lidocaine likely to benefit a patient having an MI.
- Lidocaine is especially useful when symptomatic ectopy is associated with a prolonged QT interval, as it does not lengthen the QT interval as other antiarrhythmic agents do.
- Amiodarone is also a useful agent to suppress ectopy/VT if hemodynamically significant. Additional beneficial effects include coronary vasodilation and increased cardiac output via a reduction in systemic vascular resistance.
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