Treatment of Premature Ventricular Complexes - PVCs

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Premature ventricular complexes, or PVCs, are among the most common of the cardiac arrhythmias. Unfortunately, their medical significance - and therefore their treatment - is often confusing to many doctors and patients.

If you have PVCs, your treatment should depend on the answer to two questions:

First, do you have underlying heart disease?

And second, how severe are the symptoms produced by the PVCs?

PVCs themselves are rarely dangerous. While statistically PVCs are associated with an increased risk of dying, that increased risk is mainly due to the presence of underlying heart disease and to risk factors for cardiac disease. The PVCs themselves, in general, are thought to be largely benign.

The First Treatment Goal - Reduce Cardiac Risk

Because PVCs are often associated with underlying heart disease, your doctor should perform a cardiac evaluation when he or she first discovers them.

If it turns out that you have heart disease, adequate treatment of your cardiac condition will often eliminate or lessen the frequency of PVCs. This is especially true if you have coronary artery disease (CAD) or heart failure.

In some rare individuals, extremely frequent PVCs are now thought to be responsible for producing cardiomyopathy (weak heart muscle).

So, if unexplained cardiomyopathy is found in the presence of very frequent PVCs, it may be helpful to treat the PVCs to see if the cardiomyopathy improves.

If your doctor finds your heart to be healthy, that's a very good thing. However, PVCs are also associated with several risk factors for CAD, especially hypertension.

So you and your doctor should do a thorough assessment of all your cardiac risk factors and embark on an aggressive program to get them under control. In addition to reducing your risk for CAD, this effort may very well also reduce your PVCs.

The Second Treatment Goal - Reduce Symptoms

Fortunately, most people who have PVCs do not "feel" them at all. However, some perceive their PVCs as palpitations, which they usually describe as "skips" or "pounding" that can vary from mildly annoying to extremely disturbing.

So, in addition to doing an evaluation for heart disease, sometimes it is necessary to consider doing something about the PVCs themselves, in order to reduce symptoms.

The treatment of PVCs would be easy if we had antiarrhythmic drugs that were both safe and effective at getting rid of PVCs. Unfortunately, this is not the case. So deciding whether to treat PVCs, and how to treat them, is often more difficult than you might think.

If your PVCs are not causing symptoms, or if the palpitations you experience are not troublesome to you, the best thing to do is leave them alone. However, if your PVCs are causing palpitations sufficient to disrupt your life, then you and your doctor should discuss the options for treating PVCs.

First, you should try eliminating your intake of caffeine, which can increase the frequency of PVCs in people who are sensitive to caffeine. The same thing goes for tobacco products and alcohol. There's also evidence that regular exercise can reduce palpitations.

If your attempts to make appropriate lifestyle changes do not give you sufficient relief, you and your doctor may want to consider a trial of drug therapy.

If you opt for drug therapy, it is usually a good idea to start with a trial of beta blockers - drugs that blunt the effect of adrenaline. Beta blockers are not as effective as "true" antiarrhythmic drugs at eliminating PVCs, but they are safe and usually well tolerated. While they may reduce the PVCs themselves, they work better at reducing the symptoms PVCs cause.

The more powerful antiarrhythmic drugs are often reasonably effective at suppressing PVCs. However, these drugs are prone to cause significant problems. Chief among them is a tendency to cause "proarrhythmia" - that is, actually triggering arrhythmias that are far more dangerous than the PVCs. Proarrhythmia is particularly likely in people who have underlying heart disease, but it can happen to anyone. In addition, each antiarrhythmic drug has its own unique toxicity profile that renders this class of drugs among the most toxic used in medicine.

Finally, in patients whose PVCs are extremely disturbing and cannot be safely treated with lifestyle changes or drugs, it may be possible for an electrophysiologist to treat them with ablation therapy - electrically mapping the location that is producing the PVCs, and cauterizing it through a special cardiac catheter.

The bottom line is that, because PVCs themselves are rarely dangerous, the aggressiveness applied to their therapy should be based almost completely on how much the PVCs are disrupting your life. While it is fortunate that PVCs usually cause only minimal symptoms, that fact doesn't help much if you are one of the unlucky few whose PVCs are highly bothersome. In this case you will need to find a knowledgeable and sympathetic doctor who can help you go through all the treatment options and devise a strategy that is right for you.

Sources:

Zipes, DP, Camm, AJ, Borggrefe, M, et al. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death-Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol 2006; 48:1064.

Yokokawa M, Good E, Crawford T, et al. Recovery from left ventricular dysfunction after ablation of frequent premature ventricular complexes. Heart Rhythm 2013; 10:172.

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