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Should You Evaluate for CAD in Seniors with Premature Ventricular

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Should You Evaluate for CAD in Seniors with Premature Ventricular From the CLINICAL INQUIRIES Family Physicians Inquiries Network Michelle B. Nobles, MD, Should you evaluate for CAD and John P. Langlois, MD Mountain Area Health Education in seniors with premature Center Geriatric Medicine Fellowship, Asheville, NC Sue Stigleman, MLS ventricular contractions? Mountain Area Health Education Center Health Sciences Library, Asheville, NC Evidence-based answer Yes. Current guidelines suggest increased mortality from all causes in evaluating patients with premature elderly patients with a history of CAD, left ventricular contractions (PVCs) and ventricular dysfunction, hypertension, or associated risk factors for underlying valvular heart disease. Frequent PVCs coronary artery disease (strength of during recovery from exercise stress ® recommendation [SOR]: C, expert Dowdentesting are also Healthassociated withMedia increased opinion). mortality. Frequent PVCs areCopyright associated with There is strong evidence against acute myocardial infarction and suddenFor personalsuppressing PVCs use with only antiarrhythmics death in patients without known coronary (SOR: A, randomized controlled trials artery disease (CAD). They are linked to [RCTs]). FAST TRACK Clinical commentary Frequent PVCs are Stress preventive measures the patient has signifi cant symptoms), but I fi nd myself discussing PVCs most also to consider whether the patient has linked to acute MI often with young women who don’t have risk factors for CAD. and sudden death known heart disease—rather than the In future discussions with patients in patients without elderly. I often discover PVCs on physical about PVCs, I plan to shift the focus to examination in the offi ce or see them on measures to prevent CAD—specifi cally known coronary a Holter monitor ordered to rule out other tobacco cessation, weight management, artery disease more worrisome arrhythmias. daily physical activity, and a healthy This reminds me that I need to not only diet. consider the issue of treatment aimed at Jennifer Lochner, MD suppressing PVCs (not helpful except when Oregon Health and Sciences University, Portland ❚ Evidence summary of Cardiology guideline defi nes frequent A consistent defi nition of frequent PVCs PVCs as >10 per hour.3 doesn’t exist in the literature. Some stud- Despite the association between fre- ies have found a signifi cant risk of death quent PVCs and increased risk of death or acute myocardial infarction associated and cardiac events, our review didn’t with >30 PVCs per hour.1,2 The 2006 fi nd studies that indicate the utility of American College of Cardiology/Ameri- evaluation strategies for higher-risk can Heart Association/European Society patients. CONTINUED www.jfponline.com VOL 57, NO 5 / MAY 2008 325 For mass reproduction, content licensing and permissions contact Dowden Health Media. TABLE INQUIRIES Suppressing PVCs is a bad idea Characteristics of patients with PVCs Studies have evaluated whether suppress- who are at higher risk of cardiac disease/death ing PVCs with antiarrhythmic agents improves prognosis. Both Cardiac Ar- PATIENT rhythmia Suppression Trials (CAST I: CHARACTERISTICS LOWER RISK HIGHER RISK CLINICAL encainide and fl ecainide; CAST II: mori- Morphology Unifocal PVCs Complex multifocal PVCs <10 PVCs per hour Ventricular tachycardia cizine) showed that suppressing frequent Ventricular fi brillation PVCs signifi cantly increased mortality in >10 PVCs per hour the treatment groups.5,6 Symptoms Asymptomatic Palpitations Presyncope Recommendations Syncope In 2006, the American College of Cardi- Preexisting None Known history of CAD ology, American Heart Association, and conditions Structural heart disease Valvular heart disease European Society of Cardiology pub- Cardiomyopathy lished their Guidelines for Management of Patients with Ventricular Arrhythmias CAD, coronary artery disease, PVCs, premature ventricular contractions. and the Prevention of Sudden Cardiac Source: American College of Cardiology et al.3 Death.3 The TABLE summarizes characteris- Frequent PVCs predict tics of patients with PVCs who were at increased mortality higher risk of underlying cardiac disease The Framingham study looked at the and death. All patients with PVCs should prognostic implications of frequent PVCs have a history and physical examination, (>30 per hour) in a cohort of symptom- electrocardiogram, and electrolyte studies. atic patients examined over a 6-year pe- Higher-risk patients should be considered riod.1 Men, but not women, had a signifi - for further evaluation, including stress test- cant increase in all-cause mortality (rela- ing, echocardiography, and ambulatory tive risk [RR]=2.36; 95% confi dence electrocardiogram (SOR: C, opinion). ■ FAST TRACK interval [CI], 1.65-3.2) and myocardial There is strong infarction or sudden death (RR=2.12; References 95% CI, 1.33-3.38). The Copenhagen 1. Bikkina M, Larson MG, Levy D. Prognostic impli- evidence against Holter study of a cohort of healthy pa- cations of asymptomatic ventricular arrhythmias: the Framingham heart study. Ann Intern Med. suppressing tients demonstrated an increased risk of 1992;117:990-996. PVCs with myocardial infarction or cardiovascular 2. Sajadieh A, Nielsen OW, Rasmussen V, et al. Ven- death in patients with >30 PVCs per tricular arrhythmias and risk of death and acute antiarrhythmics myocardial infarction in apparently healthy subjects hour (hazard ratio [HR]=2.85, 95% CI, of age 55 or older. Am J Cardiol. 2006;97:1351- 1.16-7.0).2 1357. Frequent PVCs occurring during 3. American College of Cardiology, American Heart recovery from stress testing are also Association, European Society of Cardiology. ACC/ AHA/ESC 2006 guidelines for management of pa- associated with increased mortality. tients with ventricular arrhythmias and the preven- A large prospective cohort study fol- tion of sudden cardiac death. J Am Coll Cardiol. lowed more than 29,000 patients with 2006;48:e247-e346. 4. Frolkis JP, Pothier CE, Blackstone EH, et al. Fre- varying degrees of risk for 5 years. Af- quent ventricular ectopy after exercise as a predic- ter adjusting for confounding variables, tor of death. N Engl J Med. 2003;348:781-790. frequent PVCs (≥7 per minute or more 5. The Cardiac Arrhythmia Suppression Trial (CAST) complex ventricular ectopy) during Investigators. Preliminary report: effect of encainide and fl ecainide on mortality in a randomized trial of recovery predicted an increased risk arrhythmia suppression after myocardial infarction. of death (HR=1.5; 95% CI, 1.1-1.9). N Engl J Med. 1989;321:406-412. Frequent PVCs arising during exercise 6. The Cardiac Arrhythmia Suppression Trial II Inves- tigators. Effect of the antiarrhythmic agent morici- stress testing were not associated with zine on survival after myocardial infarction. N Engl increased risk.4 J Med. 1992;327:227-233. 326 VOL 57, NO 5 / MAY 2008 THE JOURNAL OF FAMILY PRACTICE.
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