Submitted Successfully!
To reward your contribution, here is a gift for you: A free trial for our video production service.
Thank you for your contribution! You can also upload a video entry or images related to this topic.
Version Summary Created by Modification Content Size Created at Operation
1
Dimitrios Tsiachris
 -- 1167 2023-10-07 18:57:58 |
2 format correct
Catherine Yang
 Meta information modification 1167 2023-10-08 02:30:57 |

Video Upload Options

Do you have a full video?
Send video materials Upload full video

Confirm

Are you sure to Delete?
Yes No
Cite
If you have any further questions, please contact Encyclopedia Editorial Office.
Tsiachris, D.; Botis, M.; Doundoulakis, I.; Bartsioka, L.I.; Tsioufis, P.; Kordalis, A.; Antoniou, C.; Tsioufis, K.; Gatzoulis, K.A. Premature Ventricular Complexes. Encyclopedia. Available online: https://encyclopedia.pub/entry/49919 (accessed on 03 August 2024).
Tsiachris D, Botis M, Doundoulakis I, Bartsioka LI, Tsioufis P, Kordalis A, et al. Premature Ventricular Complexes. Encyclopedia. Available at: https://encyclopedia.pub/entry/49919. Accessed August 03, 2024.
Tsiachris, Dimitris, Michail Botis, Ioannis Doundoulakis, Lamprini Iro Bartsioka, Panagiotis Tsioufis, Athanasios Kordalis, Christos-Konstantinos Antoniou, Konstantinos Tsioufis, Konstantinos A. Gatzoulis. "Premature Ventricular Complexes" Encyclopedia, https://encyclopedia.pub/entry/49919 (accessed August 03, 2024).
Tsiachris, D., Botis, M., Doundoulakis, I., Bartsioka, L.I., Tsioufis, P., Kordalis, A., Antoniou, C., Tsioufis, K., & Gatzoulis, K.A. (2023, October 07). Premature Ventricular Complexes. In Encyclopedia. https://encyclopedia.pub/entry/49919
Tsiachris, Dimitris, et al. "Premature Ventricular Complexes." Encyclopedia. Web. 07 October, 2023.
Premature Ventricular Complexes
Edit
This entry is adapted from the peer-reviewed paper 10.3390/diagnostics13193094

Premature ventricular complexes (PVCs) are frequently encountered in clinical practice. The association of PVCs with adverse cardiovascular outcomes is well established in the context of structural heart disease, yet not so much in the absence of structural heart disease.

premature ventricular contractions catheter ablation electrocardiography

1. Epidemiology

Premature ventricular complexes (PVCs) constitute one of the most common arrhythmias encountered in clinical practice. Contemporary data suggest an increasing incidence of idiopathic PVCs, defined as PVCs without apparent structural heart disease [1]. The prevalence of PVCs is proportional to the monitoring duration. A study among 122 043 US Air Force personnel demonstrated at least 1 PVC in 8 per 1000 participants, during a 48-s ECG recording [2]. PVCs were detected in 5.5% of participants in the Atherosclerosis Risk in Communities (ARIC) study, based on a 2 min ECG [3].
Notably, there are no epidemiological data on the prevalence high burden (>5 or 10%) idiopathic (i.e., without concomitant structural heart disease) PVCs in random Holter monitoring data. When 24 h Holter monitoring was implemented among healthy adults, 69% of participants had at least one PVC, with a median PVC count of 2 and a 95th percentile of 193 PVCs [4]. In a population of 1424 community-dwelling individuals who underwent Holter monitoring, increasing age, smoking status, elevated systolic blood pressure, and impaired left ventricular ejection fraction were independently associated with increased PVC frequency [5]. Even though most patients with PVCs experience no symptoms, PVC-related symptoms can lead to worsened quality-of-life and include palpitations, chest discomfort and dizziness [6]. Interestingly, periods of bigeminy and trigeminy appear most commonly during rest and cause pseudo-bradycardia or, more accurately, bradysphygmia and subsequent fatigue since PVCs often do not generate peripheral pulse and impair cardiac output.

2. Natural History

Regarding asymptomatic idiopathic PVCs natural history, the existing body of literature provides discordant findings. Day-by-day fluctuations in PVC burden have been reported in patients undergoing 14-day monitoring, but most data are based on 24 h recordings [7].
Gaita et al. [8] reported that among 55 patients who were followed up for 15 years, PVCs spontaneously resolved in half of them. Similarly, among a paediatric population without structural heart disease, PVCs resolved during follow-up in 28% of patients (estimated mean time to disappearance 115 months) [9]. Lee et al. more recently reported spontaneous remission in 44% of study population, at a median follow-up time of 15.4 months [10]. Gatzoulis et al. reported similar rates of satisfactory response between antiarrhythmic drug recipients (82%) and non-recipients (86%), among idiopathic RVOT symptomatic patients [11].
In contrast, no significant change in PVC prevalence was reported in 239 asymptomatic patients with normal left ventricle, over 5.6 years [12]. It should be noted that this study included patients with an initially diagnosed high PVC burden of 10%. Initiation point of follow-up is crucial since increased PVC burden is usually asymptomatic and remission, if ever occurring, this will take place in the first months.

3. Prognosis

PVCs have consistently been associated with adverse cardiovascular outcomes among patients with pre-existing structural heart disease. The association between PVCs and increased mortality in the context of ischemic heart disease is well established, as numerous historical studies provide relevant data [13][14][15]. Initial efforts for pharmacological suppression of PVCs in survivors of myocardial infarction, using class IC antiarrhythmics, led to detrimental effects on total mortality [16], now known to stem from the untoward interplay between abnormal substrate (scar and ischemia) and pharmacodynamics of this particular class. Concerning non-ischemic systolic heart failure, a sub-group analysis of the DANISH study, among patients with left ventricle ejection fraction (LVEF) ≤ 35%, high PVC burden (defined as more than 30 PVCs per hour) was associated with a 38% higher risk of death from any cause and a 78% higher risk of cardiovascular mortality [17].
The association between the presence of PVCs in patients with apparently normal hearts and adverse cardiovascular outcomes has been a matter of debate. A hallmark study in 1985 reported no difference in prognosis between 70 asymptomatic, healthy participants with ventricular ectopy and the general population [18]. In the first meta-analysis of prospective cohort studies of participants without clinically apparent heart disease, the presence of PVCs was associated with worse cardiovascular outcomes [19]. However, the exclusion of structural heart disease was not based on advanced tests, and the risk was also correlated with presence of cardiovascular risk factors.
The Cardiovascular Health Study (CHS) was a landmark study of 1429 24 h ambulatory ECG recipients that demonstrated a 31% increased risk of death and a 48% increased risk for incident heart failure in the upper quartile of PVC frequency compared to those in the lowest quartile [20].
In the context of resolving this discrepancy, cardiac magnetic resonance (CMR) has emerged as a pivotal tool in the assessment of PVCs prognosis. In a cohort of 518 patients in whom PVCs were deemed as asymptomatic after negative routine diagnostic workup, subjects with myocardial abnormalities on CMR were at increased risk for the composite outcome of sudden cardiac death, resuscitated cardiac arrest and episodes of ventricular fibrillation-ventricular tachycardia [21]. Patients with multifocal PVCs and non-left bundle branch block morphology had increased incidence of abnormal CMR findings.

4. Arrhythmia Mechanism and Substrate

In the modern era, an absence of structural heart disease has to be confirmed by CMR. In a single-center prospective study of patients with significant PVC burden, (>1.000 but <10.000, or presence of NSVT) and normal findings at echocardiography, structural heart disease was diagnosed in 25.5% (mostly myocarditis) and non-specific abnormal findings were present in 20% [22].
The mechanism of idiopathic frequent PVCs is not related to myocardial scarring, suggesting either an increased triggered activity or the presence of a micro-reentry [23][24]—also explaining the tendency to flare up during lower heart rates. The sites of successful catheter ablation of idiopathic PVC origins have been progressively elucidated and include both the endocardium and, less commonly, the epicardium. Idiopathic PVCs usually originate from specific anatomical structures such as the ventricular outflow tracts, aortic root, atrioventricular annuli, papillary muscles, Purkinje network, and exhibit characteristic electrocardiograms based on their anatomical background [25].
With respect to PVCs originating specifically from the right ventricular outflow tract, subclinical myocarditis not detectable with current CMR techniques seems to be the underlying mechanism. In the case of aortic root, extensive fibrous tissue presents between the base the cusps and LV myocardium appears as the most plausible factor [26].

5. PVC-Induced Myocardial Dysfunction

An increasing body of evidence has revealed that frequent PVCs can lead to impairment of ventricular function (PVC-induced cardiomyopathy), which is a potentially reversible condition after PVC elimination [27]. PVC burden has been shown to be the strongest independent predictor of PVC-induced cardiomyopathy in several studies [27][28][29].
The cut-off value that separates those at high risk of PVC-induced cardiomyopathy ranges from 16% to 26%, in different studies [29][30][31]. Current guidelines report that a PVC burden of 10% seems to be the minimal threshold for development of LV dysfunction, with higher risk when the PVC burden is >20% [27][29].
Other risk factors include PVC-QRS width of >150 ms [32], asymptomatic status [33], and interpolated PVCs [34]. Male sex and epicardial origin of the arrhythmia are also independent predictors of PVC-induced myocardial dysfunction [35]. Elimination of PVCs often leads to improvement or resolution of cardiomyopathy [29][31]. Interestingly, therapeutic benefit of PVC suppression extends to patients with concomitant, but causally unrelated, structural heart disease [36]. A wider QRS during SR is a poor prognostic marker for EF recovery following PVC catheter ablation [37].

References

  1. Sirichand, S.; Killu, A.M.; Padmanabhan, D.; Hodge, D.O.; Chamberlain, A.M.; Brady, P.A.; Kapa, S.; Noseworthy, P.A.; Packer, D.L.; Munger, T.M.; et al. Incidence of Idiopathic Ventricular Arrhythmias: A Population-Based Study. Circ. Arrhythm. Electrophysiol. 2017, 10, e004662.
  2. Hiss, R.G.; Lamb, L.E. Electrocardiographic findings in 122,043 individuals. Circulation 1962, 25, 947–961.
  3. Simpson, R.J., Jr.; Cascio, W.E.; Schreiner, P.J.; Crow, R.S.; Rautaharju, P.M.; Heiss, G. Prevalence of premature ventricular contractions in a population of African American and white men and women: The Atherosclerosis Risk in Communities (ARIC) study. Am. Heart J. 2002, 143, 535–540.
  4. Von Rotz, M.; Aeschbacher, S.; Bossard, M.; Schoen, T.; Blum, S.; Schneider, S.; Estis, J.; Todd, J.; Risch, M.; Risch, L.; et al. Risk factors for premature ventricular contractions in young and healthy adults. Heart 2017, 103, 702–707.
  5. Kerola, T.; Dewland, T.A.; Vittinghoff, E.; Heckbert, S.R.; Stein, P.K.; Marcus, G.M. Modifiable Predictors of Ventricular Ectopy in the Community. J. Am. Heart Assoc. 2018, 7, e010078.
  6. Lee, A.; Denman, R.; Haqqani, H.M. Ventricular Ectopy in the Context of Left Ventricular Systolic Dysfunction: Risk Factors and Outcomes Following Catheter Ablation. Heart Lung Circ. 2019, 28, 379–388.
  7. Voskoboinik, A.; Hadjis, A.; Alhede, C.; Im, S.I.; Park, H.; Moss, J.; Marcus, G.M.; Hsia, H.; Lee, B.; Tseng, Z.; et al. Predictors of adverse outcome in patients with frequent premature ventricular complexes: The ABC-VT risk score. Heart Rhythm 2020, 17, 1066–1074.
  8. Gaita, F.; Giustetto, C.; Di Donna, P.; Richiardi, E.; Libero, L.; Brusin, M.C.; Molinari, G.; Trevi, G. Long-term follow-up of right ventricular monomorphic extrasystoles. J. Am. Coll. Cardiol. 2001, 38, 364–370.
  9. Tsuji, A.; Nagashima, M.; Hasegawa, S.; Nagai, N.; Nishibata, K.; Goto, M.; Matsushima, M. Long-term follow-up of idiopathic ventricular arrhythmias in otherwise normal children. Jpn. Circ. J. 1995, 59, 654–662.
  10. Lee, A.K.Y.; Andrade, J.; Hawkins, N.M.; Alexander, G.; Bennett, M.T.; Chakrabarti, S.; Laksman, Z.W.; Krahn, A.; Yeung-Lai-Wah, J.A.; Deyell, M.W. Outcomes of untreated frequent premature ventricular complexes with normal left ventricular function. Heart 2019, 105, 1408–1413.
  11. Gatzoulis, K.A.; Archontakis, S.; Vlasseros, I.; Tsiachris, D.; Vouliotis, A.; Arsenos, P.; Dilaveris, P.; Sideris, S.; Karystinos, G.; Skiadas, I.; et al. Complex right ventricular outflow tract ectopy in the absence of organic heart disease. Results of a long-term prospective observational study. Int. J. Cardiol. 2014, 172, e351–e353.
  12. Niwano, S.; Wakisaka, Y.; Niwano, H.; Fukaya, H.; Kurokawa, S.; Kiryu, M.; Hatakeyama, Y.; Izumi, T. Prognostic significance of frequent premature ventricular contractions originating from the ventricular outflow tract in patients with normal left ventricular function. Heart 2009, 95, 1230–1237.
  13. Mukharji, J.; Rude, R.E.; Poole, W.K.; Gustafson, N.; Thomas, L.J., Jr.; Strauss, W.; Jaffe, A.S.; Muller, J.E.; Roberts, R.; Raabe, D.S., Jr.; et al. Risk factors for sudden death after acute myocardial infarction: Two-year follow-up. Am. J. Cardiol. 1984, 54, 31–36.
  14. Bigger, J.T., Jr.; Fleiss, J.L.; Kleiger, R.; Miller, J.P.; Rolnitzky, L.M. The relationships among ventricular arrhythmias, left ventricular dysfunction, and mortality in the 2 years after myocardial infarction. Circulation 1984, 69, 250–258.
  15. Moss, A.J.; Davis, H.T.; DeCamilla, J.; Bayer, L.W. Ventricular ectopic beats and their relation to sudden and nonsudden cardiac death after myocardial infarction. Circulation 1979, 60, 998–1003.
  16. Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: Effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N. Engl. J. Med. 1989, 321, 406–412.
  17. Boas, R.; Thune, J.J.; Pehrson, S.; Kober, L.; Nielsen, J.C.; Videbaek, L.; Haarbo, J.; Korup, E.; Bruun, N.E.; Brandes, A.; et al. Prevalence and prognostic association of ventricular arrhythmia in non-ischaemic heart failure patients: Results from the DANISH trial. Europace 2021, 23, 587–595.
  18. Kennedy, H.L.; Whitlock, J.A.; Sprague, M.K.; Kennedy, L.J.; Buckingham, T.A.; Goldberg, R.J. Long-term follow-up of asymptomatic healthy subjects with frequent and complex ventricular ectopy. N. Engl. J. Med. 1985, 312, 193–197.
  19. Lee, V.; Hemingway, H.; Harb, R.; Crake, T.; Lambiase, P. The prognostic significance of premature ventricular complexes in adults without clinically apparent heart disease: A meta-analysis and systematic review. Heart 2012, 98, 1290–1298.
  20. Dukes, J.W.; Dewland, T.A.; Vittinghoff, E.; Mandyam, M.C.; Heckbert, S.R.; Siscovick, D.S.; Stein, P.K.; Psaty, B.M.; Sotoodehnia, N.; Gottdiener, J.S.; et al. Ventricular Ectopy as a Predictor of Heart Failure and Death. J. Am. Coll. Cardiol. 2015, 66, 101–109.
  21. Muser, D.; Santangeli, P.; Castro, S.A.; Casado Arroyo, R.; Maeda, S.; Benhayon, D.A.; Liuba, I.; Liang, J.J.; Sadek, M.M.; Chahal, A.; et al. Risk Stratification of Patients with Apparently Idiopathic Premature Ventricular Contractions: A Multicenter International CMR Registry. JACC Clin. Electrophysiol. 2020, 6, 722–735.
  22. Andreini, D.; Dello Russo, A.; Pontone, G.; Mushtaq, S.; Conte, E.; Perchinunno, M.; Guglielmo, M.; Santos, A.C.; Magatelli, M.; Baggiano, A.; et al. CMR for Identifying the Substrate of Ventricular Arrhythmia in Patients with Normal Echocardiography. JACC Cardiovasc. Imaging 2020, 13 Pt 1, 410–421.
  23. Gatzoulis, K.A.; Archontakis, S.; Dilaveris, P.; Tsiachris, D.; Arsenos, P.; Sideris, S.; Stefanadis, C. Ventricular arrhythmias: From the electrophysiology laboratory to clinical practice. Part II: Potentially malignant and benign ventricular arrhythmias. Hell. J. Cardiol. 2012, 53, 217–233.
  24. Gatzoulis, K.A.; Archontakis, S.; Dilaveris, P.; Tsiachris, D.; Arsenos, P.; Sideris, S.; Stefanadis, C. Ventricular arrhythmias: From the electrophysiology laboratory to clinical practice. Part I: Malignant ventricular arrhythmias. Hell. J. Cardiol. 2011, 52, 525–535.
  25. Yamada, T.; Kay, G.N. Anatomical Consideration in Catheter Ablation of Idiopathic Ventricular Arrhythmias. Arrhythm. Electrophysiol. Rev. 2016, 5, 203–209.
  26. Yamada, T.; Litovsky, S.H.; Kay, G.N. The left ventricular ostium: An anatomic concept relevant to idiopathic ventricular arrhythmias. Circ. Arrhythm. Electrophysiol. 2008, 1, 396–404.
  27. Zeppenfeld, K.; Tfelt-Hansen, J.; de Riva, M.; Winkel, B.G.; Behr, E.R.; Blom, N.A.; Charron, P.; Corrado, D.; Dagres, N.; de Chillou, C.; et al. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur. Heart J. 2022, 43, 3997–4126.
  28. Roca-Luque, I.; Mont, L. Frequent premature ventricular complexes and normal ejection fraction: To treat or not to treat? Heart 2019, 105, 1386–1387.
  29. Baman, T.S.; Lange, D.C.; Ilg, K.J.; Gupta, S.K.; Liu, T.Y.; Alguire, C.; Armstrong, W.; Good, E.; Chugh, A.; Jongnarangsin, K.; et al. Relationship between burden of premature ventricular complexes and left ventricular function. Heart Rhythm 2010, 7, 865–869.
  30. Ban, J.E.; Park, H.C.; Park, J.S.; Nagamoto, Y.; Choi, J.I.; Lim, H.E.; Park, S.W.; Kim, Y.H. Electrocardiographic and electrophysiological characteristics of premature ventricular complexes associated with left ventricular dysfunction in patients without structural heart disease. Europace 2013, 15, 735–741.
  31. Hasdemir, C.; Ulucan, C.; Yavuzgil, O.; Yuksel, A.; Kartal, Y.; Simsek, E.; Musayev, O.; Kayikcioglu, M.; Payzin, S.; Kultursay, H.; et al. Tachycardia-induced cardiomyopathy in patients with idiopathic ventricular arrhythmias: The incidence, clinical and electrophysiologic characteristics, and the predictors. J. Cardiovasc. Electrophysiol. 2011, 22, 663–668.
  32. Yokokawa, M.; Kim, H.M.; Good, E.; Crawford, T.; Chugh, A.; Pelosi, F., Jr.; Jongnarangsin, K.; Latchamsetty, R.; Armstrong, W.; Alguire, C.; et al. Impact of QRS duration of frequent premature ventricular complexes on the development of cardiomyopathy. Heart Rhythm 2012, 9, 1460–1464.
  33. Yokokawa, M.; Kim, H.M.; Good, E.; Chugh, A.; Pelosi, F., Jr.; Alguire, C.; Armstrong, W.; Crawford, T.; Jongnarangsin, K.; Oral, H.; et al. Relation of symptoms and symptom duration to premature ventricular complex-induced cardiomyopathy. Heart Rhythm 2012, 9, 92–95.
  34. Olgun, H.; Yokokawa, M.; Baman, T.; Kim, H.M.; Armstrong, W.; Good, E.; Chugh, A.; Pelosi, F., Jr.; Crawford, T.; Oral, H.; et al. The role of interpolation in PVC-induced cardiomyopathy. Heart Rhythm 2011, 8, 1046–1049.
  35. Latchamsetty, R.; Yokokawa, M.; Morady, F.; Kim, H.M.; Mathew, S.; Tilz, R.; Kuck, K.H.; Nagashima, K.; Tedrow, U.; Stevenson, W.G.; et al. Multicenter Outcomes for Catheter Ablation of Idiopathic Premature Ventricular Complexes. JACC Clin. Electrophysiol. 2015, 1, 116–123.
  36. Penela, D.; Van Huls Van Taxis, C.; Aguinaga, L.; Fernandez-Armenta, J.; Mont, L.; Castel, M.A.; Heras, M.; Tolosana, J.M.; Sitges, M.; Ordóñez, A.; et al. Neurohormonal, structural, and functional recovery pattern after premature ventricular complex ablation is independent of structural heart disease status in patients with depressed left ventricular ejection fraction: A prospective multicenter study. J. Am. Coll. Cardiol. 2013, 62, 1195–1202.
  37. Penela, D.; Jauregui, B.; Fernandez-Armenta, J.; Aguinaga, L.; Tercedor, L.; Ordonez, A.; Acosta, J.; Bisbal, P.; Vassanelli, F.; Teres, C.; et al. Influence of baseline QRS on the left ventricular ejection fraction recovery after frequent premature ventricular complex ablation. Europace 2020, 22, 274–280.
More
© Text is available under the terms and conditions of the Creative Commons Attribution (CC BY) license; additional terms may apply. By using this site, you agree to the Terms and Conditions and Privacy Policy.
Upload a video for this entry
Information
Subjects: Cardiac & Cardiovascular Systems
Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register :
Dimitris Tsiachris
,
Michail Botis
,
Ioannis Doundoulakis
,
Lamprini Iro Bartsioka
,
Panagiotis Tsioufis
,
Athanasios Kordalis
,
Christos-Konstantinos Antoniou
,
Konstantinos Tsioufis
,
Konstantinos A. Gatzoulis
View Times: 493
Revisions: 2 times (View History)
Update Date: 08 Oct 2023
Table of Contents
    1000/1000
    Hot Most Recent
    Video Production Service
    Feedback