![Page 1: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/1.jpg)
Premature Ventricular Contractions
Matthew B. Sellers MD, MSCardiac Electrophysiology
AnMed Health Arrhythmia [email protected]
![Page 2: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/2.jpg)
Disclosures
• Under Accreditation Council for Continuing Medical Education guidelines, disclosure must be made regarding financial relationships with commercial interests within the last 12 months
• Matthew B. Sellers MD, MS
• I have no relevant financial relationships or affiliations with commercial interests to disclose
![Page 3: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/3.jpg)
Outline• Case• Prevalence• Mechanism• Associated conditions• Clinical presentation• Evaluation• Prognosis
![Page 4: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/4.jpg)
Case• 68yo WM with CAD s/p inferior MI c/b ischemic
cardiomyopathy (EF 45%), RBBB, PVCs, NSVT presented with frequent PVCs and symptoms of fatigue and shortness of breath
• No syncope, presyncope
• Holter: 36,000 PVCs (30%), periods of bigeminy, trigeminy and NSVT
• Intolerant to beta-blockers
![Page 5: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/5.jpg)
ECG
![Page 6: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/6.jpg)
Prevalence• Duration of monitoring
• 1% on 12 lead ECG• 80% on 24 hour holter monitor
![Page 7: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/7.jpg)
Mechanism
• Re-entry
• Enhanced normal or abnormal automaticity
• Triggered activity
![Page 8: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/8.jpg)
Associated Conditions• Hypertension with LVH• Acute myocardial infarction• Heart failure• Hypertrophic cardiomyopathy• Congenital heart disease• Idiopathic ventricular tachycardia• Other: OSA, COPD, pHTN, stimulants,
endocrinopathies
![Page 9: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/9.jpg)
Clinical Presentation• Asymptomatic• Palpitations, lightheadedness• Anxiety
• Palpitations anxiety catecholamine surge ectopy axiety
• Reversible cardiomyopathy
![Page 10: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/10.jpg)
Evaluation• History, exam• 12 lead ECG• Ambulatory monitoring• Transthoracic echocardiogram• Exercise treadmill stress test
• ? Electrolytes, OSA screening, UDS
![Page 11: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/11.jpg)
Electrocardiography
• QRS duration > 120 msec
• Bizarre morphology (not typical aberration)
• T wave in opposite direction of main QRS
• Fully compensatory pause
![Page 12: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/12.jpg)
RVOT PVCs
![Page 13: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/13.jpg)
Prognosis in “Normal Hearts”• ARIC single PVC on 2 minute ECG had 2 fold
increase in mortality from CHD• ARIC 2 fold increase in sudden cardiac death• Meta-analysis 8 prospective studies (3,629 persons) PVC
was associated with increased all cause mortality, cardiovascular mortality, SCD, or ischemic CHD (OR 1.72, 95% CI 1.28-2.31)
• Meta-analysis 106,195 persons 1 PVC on 10 second ECG or >30 in 1 hour recording associated with overall cardiac mortality (RR 2.1, 95% CI 1.7-2.5) and SCD
• Several cohort studies report no clinical significance
![Page 14: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/14.jpg)
Exercise• Withdrawal of vagal tone• Sympathetic stimulation increased circulating
catecholamines• Increased HR, AV conduction, contractility• Increased cardiac output and oxygen delivery
• Initiate abnormal automaticity, triggered activity, re-entry
![Page 15: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/15.jpg)
Cellular Mechanisms
![Page 16: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/16.jpg)
Specific Conditions• Exercise
• Structural heart disease
• Myocardial infarction
• CHF
![Page 17: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/17.jpg)
![Page 18: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/18.jpg)
Catecholaminergic PVT• Inherited disorder• Syncope, sudden death• Presents in children and teenagers• Structurally normal heart• Normal ECG• VT elicited by physical and emotional stress• Bidirectional ventricular tachycardia• Syncope or cardiac arrest before 40• Beta-blockers, ICD
![Page 19: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/19.jpg)
Bidirectional VT
![Page 20: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/20.jpg)
Acute MI• PVCs are seen in the majority of MIs
• <48 hours do not appear to affect prognosis
• Conflicting data after 48 hours
• PVCs carry a worse prognosis
![Page 21: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/21.jpg)
CHF• PVCs are very common in CHF
• >10 per hour, incidence of NSVT is 90%
• Prior MI associated with an increased risk of death, especially with LV dysfunction
• NSVT does not add additional risk
![Page 22: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/22.jpg)
Treatment• Reserved for symptoms or cardiomyopathy
• Beta blockers, CCB
• Antiarrhythmic therapy
• Catheter ablation
![Page 23: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/23.jpg)
![Page 24: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/24.jpg)
![Page 25: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/25.jpg)
CAST• PVCs are associated with an increased risk of sudden
and nonsudden cardiac death after MI
• 6 days to 2 years post MI• EF of less than 55%• Patients were randomly assigned after establishment
of arrhythmia suppression
![Page 26: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/26.jpg)
![Page 27: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/27.jpg)
![Page 28: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/28.jpg)
![Page 29: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/29.jpg)
![Page 30: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/30.jpg)
![Page 31: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/31.jpg)
Catheter Ablation• ACC/AHA Guidelines
• Frequent, symptomatic, monomorphic PVCs• > 10,000 PVCs on 24 hour monitor
• Drug resistant, or patient preference
• Ventricular arrhythmia storm initiated by single PVC
![Page 32: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/32.jpg)
![Page 33: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/33.jpg)
![Page 34: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/34.jpg)
Conclusion• Repetitive monomorphic ventricular ectopy
originating from the right ventricular outflow tract is an underappreciated cause of unexplained cardiomyopathy.
• Successful ablation of the focal source of ventricular ectopy results in normalization of left ventricular function
![Page 35: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/35.jpg)
Case Conclusion
![Page 36: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/36.jpg)
Case Conclusion
![Page 37: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/37.jpg)
Conclusions• Most patients have PVCs
• Symptoms, frequency
• Structural heart disease
• PVC cardiomyopathy is typically reversible with catheter radiofrequency ablation
![Page 38: Premature Ventricular Contractions - AnMed Healthanmedhealth.org/portals/16/sellers-cvs16.pdfPremature Ventricular Contractions ... • History, exam ... • Several cohort studies](https://reader031.vdocuments.us/reader031/viewer/2022022515/5afa76117f8b9abd588e559a/html5/thumbnails/38.jpg)
Questions