PVCs are generally benign in patients without structural heart disease, but a higher frequency of PVCs is associated with an increased risk of heart failure and mortality.^2,3

In asymptomatic patients, PVCs may manifest as an irregular pulse or as an incidental finding on an electrocardiogram (ECG). Others experience palpitations, dyspnoea, presyncope, and fatigue.^1,2

Several factors contribute to PVCs, including:¹

• Illicit drug use (alcohol, amphetamines, cocaine)
• Medications (digoxin, tricyclic antidepressants, etc)
• Electrolyte imbalances (hypokalaemia, hypomagnesaemia, hypercalcaemia)
• Hypoxia
• Hypercapnia
• Acute myocardial infarction (MI)
• Cardiomyopathies (hypertrophic, dilated)
• Myocarditis
• Myocardial contusion
• Mitral valve prolapse.

Risk factors for PVC include older age, taller height, hypertension, a history of structural heart disease as mentioned, limited physical activity, smoking, male gender, people of African ethnicity, and those with a higher heart rate.^1,4

How are PVCs diagnosed?

The latest European Society of Cardiology ventricular arrhythmias guideline recommends various diagnostic modalities. According to the guideline, a resting 12-lead ECG can reveal inherited disorders such as channelopathies (eg Brugada syndrome) and cardiomyopathies (eg hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy [ARVC]).⁵

Parameters like bundle branch block, atrioventricular block, hypertrophy, and Q waves suggest structural issues. Exercise ECG can detect silent ischaemia and rhythm disturbances. However, according to Scorza et al, more recent studies downplay the role of exercise ECG, suggesting evaluation with cardiac magnetic resonance imaging (MRI) in special situations. Ambulatory recordings and event recorders are useful to link symptoms to arrhythmias. Marcus recommends at least six days of evaluation.^3,4,5

Implantable devices monitor heart rhythm over extended periods and help diagnose severe arrhythmias. Signal-averaged ECG can identify ‘late potentials’, indicating abnormal myocardium.⁵

EKG offers cost-effective imaging of heart disorders and functional assessment. Cardiac MRI can provide detailed structure-function evaluation, which is especially valuable in ARVC. Cardiac computed tomography quantifies left ventricular (LV) volumes, and ejection fraction (EF), which can detect coronary anomalies.⁵

Myocardial perfusion single-photon emission computerised tomography can be used to evaluate ischaemic triggers, while coronary angiography can be used to assess obstructive coronary artery disease.⁵

Electrophysiological studies (EPS) induce arrhythmias, guide ablation, and evaluate arrhythmia risk. Syncope in structural heart disease can indicate inducible ventricular tachycardia. EPS is valuable in post-MI LV dysfunction but is less sensitive in non-ischaemic cardiomyopathy.⁵

How are PVCs treated?

First-line pharmacological treatments for PVCs include β-blockers and non-dihydropyridine calcium channel blockers (CCBs). These agents have proven safety records in structurally normal hearts, with β-blockers offering benefits in coronary disease or reduced LVEF cases. However, clinical trials show that β-blockers only result in a 12%-24% reduction in symptomatic outflow tract PVCs. The same is true of non-dihydropyridine CCBs.⁴

If initial pharmacotherapies are ineffective, catheter ablation is an option. The success of ablation procedures ranges from ~80% to ~95%. However, some patients prefer not to undergo catheter ablation, while in others catheter ablation may fail, or is contraindicated (eg because of frailty or multifocal PVCs).⁴

In these patients, additional anti-arrhythmic drugs (ADD) may be considered including flecainide, propafenone, sotalol, and amiodarone. According to Marcus, the latter is efficacious but less preferable due to side effects.⁴

In a 2023 comparative study, Kojić et al compared the safety and efficacy of flecainide, propafenone, and sotalol in the treatment of patients living with idiopathic PVC who experience frequent episodes.⁶

The primary endpoint was complete/near complete reduction of PVCs after an episode (PVCs burden reduction >99%), and the secondary endpoint was significant PVC burden reduction (≥80%).⁶

The primary endpoint was achieved in 56% of patients on flecainide, 11% in the propafenone group, and 21% in patients receiving sotalol. The secondary endpoint was achieved in 64% of patients on flecainide, 30% of patients in the propafenone group, and 33% of patients on sotalol.⁶

The authors concluded that compared to propafenone and sotalol, flecainide was the most effective AAD in achieving complete/near complete or significant PVC burden reduction.⁶

Conclusion

First-line pharmacological interventions, such as β-blockers and non-dihydropyridine CCBs, are safe in managing patients living with PVCs, but their efficacy range from 12%-24% in reducing symptoms. Catheter ablation is a viable option for selected patients.

For patients who prefer non-ablative treatments, or in whom ablation is not recommended, AADs like flecainide, propafenone, and sotalol, can be considered. As demonstrated in a comparative study, flecainide is an effective option for the management of patients with PVCs.

References

1. Sattar Y, Hashmi MF. Ventricular Premature Complexes. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK547713/
2. Higuchi K, Bhargave M. Management of premature ventricular complexes. BMJ Heart, 2020.
3. Scorza R, et al. Prognostic implication of premature ventricular contractions in patients without structural heart disease. EP Europace, 2023.
4. Marcus GM. Evaluation and Management of Premature Ventricular Complexes. Circulation, 2020.
5. Priori SG, et al. 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC) Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), European Heart Journal, 2015.
6. Kojić D, et al. Idiopathic premature ventricular complexes treatment: Comparison of flecainide, propafenone, and sotalol. Clinical Cardiology, 2023.