Premature Ventricular Contractions: Reassure Or Refer?
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REVIEW CME EDUCATIONAL OBJECTIVE: Readers will perform the initial assessment and treatment of ventricular contractions, CREDIT referring appropriate patients to a cardiologist BARIS AKDEMIR, MD HIRAD YARMOHAMMADI, MD, MPH M. CHADI ALRAIES, MD, FACP WAYNE O. ADKISSON, MD, FHRS, FACC Cardiovascular Division, Cardiovascular Division, University of Minnesota Cardiovascular Division, Cardiovascular Division, University of Minnesota University of Minnesota Medical School, Minneapolis University of Minnesota Medical School, Medical School, Minneapolis Medical School, Minneapolis Minneapolis Premature ventricular contractions: Reassure or refer? ABSTRACT octor, my heart ______.” Fill in the blank D with: skips, flip-flops, hiccups, stops, beats When patients present with palpitations, the primary care in my throat or chest, or any of the various physician can perform the initial evaluation and treat- ways patients describe palpitations. One can- ment for premature ventricular contractions (PVCs). Many not practice clinical medicine and not see pa- patients need only reassurance and do not need to see a tients with some variation of this chief com- cardiologist. plaint.1–3 Not every patient who complains of palpitations will be found to have premature KEY POINTS ventricular contractions (PVCs), but PVCs The focus of the initial evaluation is to determine wheth- are often part of the clinical problem. This review focuses on the initial evalua- er there is underlying structural heart disease. If there is, tion and management of PVCs in the primary early referral to a specialist is probably warranted. care setting (Figure 1). It is not intended to be a comprehensive review of the pathophysi- Idiopathic PVCs (in which there is no structural heart ology, electrophysiology, or localization and disease) have a benign prognosis. ablation of PVCs. We will discuss approaches to the initial therapy of symptomatic PVCs. Treatment of PVCs is indicated for relief of symptoms if We will not discuss catheter-based therapy in reassurance is not sufficient. detail except for which patients might benefit from referral to a clinical cardiac electrophysi- ologist. Patients who have a high PVC burden (> 10% of total Findings that should prompt consideration heartbeats, though this is a subject of debate) should for referral to a specialist (“red flags”) are sum- have an evaluation of their systolic function. If it is marized at the end of each section. The type of normal at baseline, periodic follow-up echocardiograms specialist depends to a degree on the cardiolo- should be considered. gy practice available to the referring physician. In our practice, such patients are typically seen Patients with a very high burden (> 20%) are at high risk by an electrophysiologist. In other practices, a of arrhythmia-induced cardiomyopathy. In these patients, general cardiologist might see such patients initially. referral is prudent, as some patients may opt for more aggressive treatment of their PVCs. ■ INITIAL EVALUATION A primary concern of any patient presenting In patients with severe symptoms for whom medical with a new symptom is whether the symptom management has failed, referral for consideration of is a marker of serious risk to health or life. In a catheter ablation is reasonable. patient with palpitations, the answer depends in large part on whether he or she has under- lying structural heart disease—and that is the doi:10.3949/ccjm.83a.15090 focus of the initial evaluation. 524 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 83 • NUMBER 7 JULY 2016 Downloaded from www.ccjm.org on September 23, 2021. For personal use only. All other uses require permission. AKDEMIR AND COLLEAGUES Palpitations demonstrated to be due to PVCs History of heart disease or surgery? Or Evidence of heart disease on examination or testing? Yes No Consider referral Symptoms for evaluation of heart disease and treatment Moderate or severe None or mild of PVCs Beta-blocker Reassurance or nondihydropyridine calcium channel antagonist Consider referral No Adequate response? Yes High PVC burden?a for treatment of PVCs Yes Periodic assessment of left ventricular function a The definition of “high” is unsettled. For very high PVC burdens (> 20%), referral is reasonable (see text for details). FIGURE 1. Algorithm for managing premature ventricular complexes (PVCs). Any patient who has a History: Information to ascertain ter? If they occur at rest, does activity make • When did the patient first notice the pal- them better or worse? new symptom pitations? • Are there symptoms of heart failure, such wants to know • Had there been any significant life events, as dyspnea on exertion, early fatigue, decline either illness or emotional stress, at the time in exercise or exertional capacity, orthopnea, whether it is the palpitations began? or paroxysmal nocturnal dyspnea? a marker • Does the patient have a known history of • Are there symptoms suggesting cardiac of serious risk heart disease (myocardial infarction, heart ischemia, such as substernal chest pain or dis- surgery, valvular heart disease, heart failure)? comfort, chest pain or discomfort brought on to health or life • What medications is the patient taking? by or made worse by exertion, or chest pain • Does the patient take any dietary or health relieved with rest or sublingual nitroglycerin? supplements? Ask specifically about any sup- • Have the palpitations ever been associated plements taken to help with weight loss or with syncope? Keep in mind that syncope is increase energy levels. Almost all of them transient loss of consciousness that spontane- contain caffeine or other “natural” sympatho- ously resolves with no features to suggest sei- mimetic agents. Also ask specifically about il- zures.4 Thus, a patient who reports he or she licit drug use. If the patient is accompanied by “blacks out” with the palpitations but never a parent or partner, this question can be chal- falls or slumps has not had loss of conscious- lenging. ness and therefore has not had syncope.5 • When do the palpitations occur? At random? • Is there any history of unexplained death At rest? With exercise? Time of day? In relation in the family, especially in younger people? to the menstrual cycle? (More about this later.) Is there a history of unexplained accidental • Does anything make the palpitations bet- death in young family members? CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 83 • NUMBER 7 JULY 2016 525 Downloaded from www.ccjm.org on September 23, 2021. For personal use only. All other uses require permission. PVCs: REASSURE OR REFER? Red flags obtained from the history ■ FURTHER EVALUATION: • Syncope related to palpitations EXTENDED MONITORING • Palpitations triggered by activity or exer- With luck, the patient’s typical palpitations tion will occur during ECG, in which case the • Known significant heart disease, congeni- palpitations can reasonably be attributed to tal heart disease, or history of heart surgery PVCs. If not, monitoring is required to estab- • Family history of premature unexplained lish the cause of the patient’s symptoms. sudden death in a first-degree relative. The type of monitoring to order depends Physical examination on the frequency of the palpitations. If the The physical examination should focus on de- patient reports several episodes per day, then tecting any signs of underlying heart or vascu- a 24- or 48-hour Holter monitor should both lar disease, eg: allow for a diagnosis and document the PVC • Significant murmurs burden (ie, the percent of the patient’s heart- • Abnormal S3 or S4 beats that are PVCs), or the burden of what- • Displaced and diffuse point of maximal im- ever is the cause of the patient’s palpitations. pulse or precordial heave If the palpitations are less frequent, a • Signs of right or left heart failure, or both, 14-to-30-day monitor should be considered. A eg, peripheral edema, elevation of jugular standard event recorder can confirm that the venous pulse, rales, S3, S4. palpitations are due to PVCs but does not tell you the PVC burden. For that, a system ca- Electrocardiography pable of mobile outpatient cardiac telemetry We consider 12-lead electrocardiography is needed. Several such systems are commer- (ECG) a part of the initial examination and cially available. assessment, not an ancillary test. One cannot A Holter monitor or other monitoring evaluate a patient’s complaint of palpitations system is useful in determining whether the without ECG. Ideally, ECG should include PVCs are unifocal (all look the same) or mul- In a patient a long 12-lead rhythm strip. The clinician tifocal (have more than one morphology) and should look for any evidence of underlying whether, in addition to PVCs, the patient has with structural heart disease, eg: nonsustained ventricular tachycardia or sus- palpitations, • Pathologic Q waves tained ventricular tachycardia (by definition 12-lead ECG • Long QT interval lasting longer than 30 seconds or associated • ST-segment elevation in leads V1 and V2 with symptoms of hemodynamic compromise is part of consistent with a Brugada pattern such as near-syncope). Even if the patient has the initial • Epsilon waves (seen in right ventricular ar- nonsustained ventricular tachycardia, if the rhythmogenic cardiomyopathy). heart is structurally normal the prognosis re- assessment, Examples of the above can be found at mains excellent. not ancillary sites such as ecgpedia.org. Given the importance of knowing wheth- testing er the patient has structural heart disease, we Red flags in the physical examination have a low threshold for ordering echocar- and ECG diography, especially if nonsustained ventric- Any of the above findings on physical exami- ular tachycardia has been documented. The nation or ECG should prompt consideration finding of significant systolic dysfunction on of early referral, even though we have yet echocardiography should prompt a cardiology to establish that the palpitations are due to consultation even if the physical examination PVCs. Early consultation is suggested not for is normal. In patients who have a high PVC treatment of the palpitations but for further burden, echocardiography is used to monitor evaluation of structural heart disease.