Ventricular Premature Complexes

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Ventricular premature complexes (VPCs) are ectopic impulses originating from an area distal to the His Purkinje system. VPCs are the most common ventricular arrhythmia. Assessment and treatment of VPCs is challenging and complex, and is highly dependent on the clinical context. The prognostic significance of VPCs is variable and, again, best interpreted in the context of the underlying cardiac condition.

The approach to the evaluation and management of VPCs has undergone dramatic changes in the last decade. Observational studies and inferences from typical electrophysiology studies were initially focused on ventricular ectopy triggering ventricular tachycardia (VT), which, in turn, can degenerate into ventricular fibrillation, as a mechanisms for sudden cardiac death. The treatment paradigm in the 1970s and 1980s was to eliminate VPCs in patients after myocardial infarction (MI). The Cardiac Arrhythmia Suppression Trial (CAST) and other arrhythmia suppression studies have demonstrated that eliminating VPCs with available antiarrhythmic drugs increases the risk of death to patients without providing any measurable benefit. ^[1]

Very few studies have evaluated the pathophysiology of VPCs in human subjects. Most of the information is derived from animal studies. Three common mechanisms exist for VPCs, (1) automaticity, (2) reentry, and (3) triggered activity, as follows:

Automaticity: This is the development of a new site of depolarization in nonnodal ventricular tissue, which can lead to a VPC. In animal models, focal mechanisms without evidence of macro-reentry play a major role in the origin of ventricular arrhythmia associated with ischemic cardiomyopathy. Increased automaticity could be due to electrolyte abnormalities or ischemic myocardium.

Reentry circuit: Reentry typically occurs when slow-conducting tissue (eg, infarcted myocardium) is present adjacent to normal tissue. The slow-conducting tissue could be due to damaged myocardium, as in the case of a healed MI.

Triggered activity: After depolarizations triggered by a preceding impulse can lead to premature activation if the threshold is reached, and this can cause a VPC. Afterdepolarization can occur either during (early) or after (late) completion of repolarization. Early afterdepolarizations commonly are responsible for bradycardia associated VPCs, but they also can be present with ischemia and electrolyte abnormalities.

Cardiac causes of VPCs include the following:

Acute myocardial infarction

Valvular heart disease, especially mitral valve prolapse

Cardiomyopathy (eg, ischemic, dilated, hypertrophic, infiltrative) ^[2]

Myocardial stretch

Cardiac contusion

Bradycardia

Tachycardia (high-catecholamine state)

Noncardiac causes of VPCs include the following:

Electrolyte disturbances (hypokalemia, hypomagnesemia, or hypercalcemia)

Medications (eg, digoxin, tricyclic antidepressants, aminophylline, amitriptyline, pseudoephedrine, fluoxetine)

Other drugs (eg, cocaine, amphetamines, caffeine, alcohol)

Anesthetics

Surgery

Infection

Stress

The reported prevalence of VPCs varies between studies, depending on the population studied, duration of observation, and method of detection. In asymptomatic patients, VPCs are infrequently noted when only a single 12-lead ECG is used for ascertainment. The Framingham heart study (with 1-h ambulatory ECG) suggested that the prevalence rate of 1 or more VPCs per hour was 33% in men without coronary artery disease (CAD) and 32% in women without CAD. Among patients with CAD, the prevalence rate of 1 or more VPCs was 58% in men and 49% in women. Other studies using 24-hour ambulatory monitoring showed a VPC prevalence rate of 41% in healthy teenage boys aged 14-16 years, 50-60% in healthy young adults, and 84% in healthy elderly persons aged 73-82 years. VPCs also are common in patients with hypertension, ventricular hypertrophy, cardiomyopathy, and mitral valve prolapse.

Data from the Gruppo Italiano per lo Studio della Sopravvivenza dell’Infarto Miocardico 2 study demonstrated that 64% of patients who had MI then had ventricular arrhythmia and 20% of patients had more than 10 VPCs per hour when 24-h Holter monitoring was used. ^{[3, 4]}

In a study evaluating the features of frequent idiopathic VPCs in the Korean, investigators reported a mean patient age of 54.7 ± 16.8 years and a slight female preponderance (54.8%). ^[5]  The most common typical VPC-related symptoms/signs were palpitation and a dropped beat (59.2%), whereas the most common ECG features were left bundle branch block, an inferior axis, and late precordial R-wave transition.

The Framingham heart study demonstrated increased prevalence of VPCs in men compared with women. The difference was especially higher in men with CAD than in women with CAD.

VPCs are uncommon in children (suggested prevalence rate of 0.8-2.2% from the Vanderbilt Medical Center; exact prevalence not known). Prevalence increases with age.

The prognosis depends on the frequency and characteristics of VPCs and on the type and severity of associated structural heart disease. Overall, VPCs are associated with an increased risk of death, especially when CAD is diagnosed, but the relationship between VPC frequency and mortality, even in this group, is not robust. Importantly, no survival benefit in in any population has been convincingly demonstrated as a consequence of suppressing VPCs .

In asymptomatic patients, frequent ventricular ectopy (defined as a run of 2 or more consecutive premature ventricular depolarizations or with premature ventricular depolarizations constituting over 10% of all ventricular depolarizations on any of the ECG recordings with the subject at rest, during exercise, or during recovery) recorded during exercise testing was associated with 2.5-fold increased risk of cardiovascular death. ^[6] Less frequent VPCs did not increase the risk.

In general, multimorphic VPCs connote a poorer prognosis than uniform morphologic VPCs. In patients post-MI, frequent VPCs (>10/h) are associated with increased mortality in the prethrombolytic era, but the association in patients receiving thrombolysis is weak.

In 2 studies, frequent or complex ventricular ectopy (defined as the presence of 7 or more ventricular premature beats per minute during any given stage, ventricular bigeminy, ventricular trigeminy, ventricular couplets, ventricular triplets, sustained or nonsustained ventricular tachycardia, ventricular flutter, torsade de pointes, or ventricular fibrillation) during exercise was an independent predictor of death. ^{[6, 7]} However, in another study, frequent VPCs only during exercise did not independently predict an increased risk; instead frequent VPCs during recovery was a stronger predictor of death. ^[8]

Frequent VPCs, especially when they occur in a bigeminal pattern, can cause or contribute to tachycardia-induced cardiomyopathy, which reversed by elimination of the PVCs through catheter ablation. ^{[6, 9, 10, 11]}  However, the extent to which this can be generalized to larger populations remains uncertain. Caution is in order, primarily because prior attempts at pharmacologic suppression were associated with unexpected and deleterious outcomes. ^[12]

Cantillon DJ. Evaluation and management of premature ventricular complexes. Cleve Clin J Med. 2013 Jun. 80(6):377-87. [Medline].

Yokokawa M, Kim HM, Good E, et al. Impact of QRS duration of frequent premature ventricular complexes on the development of cardiomyopathy. Heart Rhythm. 2012 Sep. 9(9):1460-4. [Medline].

Maggioni AP, Zuanetti G, Franzosi MG, et al. Prevalence and prognostic significance of ventricular arrhythmias after acute myocardial infarction in the fibrinolytic era. GISSI-2 results. Circulation. 1993 Feb. 87 (2):312-22. [Medline].

Marino P, Nidasio G, Golia G, et al. Frequency of predischarge ventricular arrhythmias in postmyocardial infarction patients depends on residual left ventricular pump performance and is independent of the occurrence of acute reperfusion. The GISSI-2 Investigators. J Am Coll Cardiol. 1994 Feb. 23 (2):290-5. [Medline].

Hwang JK, Park SJ, On YK, Kim JS, Park KM. Clinical characteristics and features of frequent idiopathic ventricular premature complexes in the Korean population. Korean Circ J. 2015 Sep. 45 (5):391-7. [Medline].

Jouven X, Zureik M, Desnos M, Courbon D, Ducimetiere P. Long-term outcome in asymptomatic men with exercise-induced premature ventricular depolarizations. N Engl J Med. 2000 Sep 21. 343(12):826-33. [Medline].

O’Neill JO, Young JB, Pothier CE, Lauer MS. Severe frequent ventricular ectopy after exercise as a predictor of death in patients with heart failure. J Am Coll Cardiol. 2004 Aug 18. 44(4):820-6. [Medline].

Frolkis JP, Pothier CE, Blackstone EH, Lauer MS. Frequent ventricular ectopy after exercise as a predictor of death. N Engl J Med. 2003 Feb 27. 348 (9):781-90. [Medline]. [Full Text].

Yokokawa M, Good E, Crawford T, et al. Recovery from left ventricular dysfunction after ablation of frequent premature ventricular complexes. Heart Rhythm. 2013 Feb. 10(2):172-5. [Medline].

Adams JC, Srivathsan K, Shen WK. Advances in management of premature ventricular contractions. J Interv Card Electrophysiol. 2012 Nov. 35(2):137-49. [Medline].

Zang M, Zhang T, Mao J, Zhou S, He B. Beneficial effects of catheter ablation of frequent premature ventricular complexes on left ventricular function. Heart. 2014 May. 100(10):787-93. [Medline].

Baman TS, Lange DC, Ilg KJ, et al. Relationship between burden of premature ventricular complexes and left ventricular function. Heart Rhythm. 2010 Jul. 7(7):865-869. [Medline].

Skranes JB, Einvik G, Namtvedt SK, et al. Biomarkers of cardiovascular injury and stress are associated with increased frequency of ventricular ectopy: a population-based study. BMC Cardiovasc Disord. 2016 Nov 22. 16 (1):233. [Medline].

Shah A, Hocini M, Haissaguerre M, Jaïs P. Non-invasive mapping of cardiac arrhythmias. Curr Cardiol Rep. 2015 Aug. 17 (8):60. [Medline].

Fung E, Jarvelin MR, Doshi RN, et al. Electrocardiographic patch devices and contemporary wireless cardiac monitoring. Front Physiol. 2015 May 27. 6:149. [Medline].

Dow J, Bhandari A, Simkhovich BZ, Hale SL, Kloner RA. The effect of acute versus delayed remote ischemic preconditioning on reperfusion induced ventricular arrhythmias. J Cardiovasc Electrophysiol. 2012 Dec. 23(12):1374-83. [Medline].

[Guideline] Buxton AE, Calkins H, Callans DJ, et al. ACC/AHA/HRS 2006 key data elements and definitions for electrophysiological studies and procedures: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (ACC/AHA/HRS Writing Committee to Develop Data Standards on Electrophysiology). J Am Coll Cardiol. 2006 Dec 5. 48(11):2360-96. [Medline].

[Guideline] 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: 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 Sep 5. 48(5):e247-346. [Medline].

Latchamsetty R, Bogun F. Premature ventricular complexes and premature ventricular complex induced cardiomyopathy. Curr Probl Cardiol. 2015 Sep. 40 (9):379-422. [Medline].

Hamer A, Mandel WJ. Treatment with digitalis and beta blockers. In: Surawicz B, Reddy CP, Prystowsky EN, eds. Tachycardias. Hingham, MA: Kluwer Academic Publishers; 1984. chapter 23.

Wang Y, Patel D, Wang DW, et al. β1-Adrenoceptor blocker aggravated ventricular arrhythmia. Pacing Clin Electrophysiol. 2013 Nov. 36 (11):1348-56. [Medline].

Haemers P, Sutherland G, Cikes M, et al. Further insights into blood pressure induced premature beats: Transient depolarizations are associated with fast myocardial deformation upon pressure decline. Heart Rhythm. 2015 Nov. 12 (11):2305-15. [Medline].

Njeim M, Bogun F. Selecting the appropriate ablation strategy: the role of endocardial and/or epicardial access. Arrhythm Electrophysiol Rev. 2015 Dec. 4 (3):184-8. [Medline].

Kiuchi MG, E Silva GR, Paz LM, Chen S, Souto GL. Proof of concept study: renal sympathetic denervation for treatment of polymorphic premature ventricular complexes. J Interv Card Electrophysiol. 2016 Nov. 47 (2):221-229. [Medline].

Richards DA, Byth K, Ross DL, Uther JB. What is the best predictor of spontaneous ventricular tachycardia and sudden death after myocardial infarction?. Circulation. 1991 Mar. 83(3):756-63. [Medline].

Stec S, Sikorska A, Zaborska B, Krynski T, Szymot J, Kułakowski P. Benign symptomatic premature ventricular complexes: short- and long-term efficacy of antiarrhythmic drugs and radiofrequency ablation. Kardiol Pol. 2012. 70(4):351-8. [Medline].

Huang ZJ, Li T, Yang MQ, Wu YL, Li YL. [Efficacy and safety of amiodarone and metoprolol in the treatment of ventricular premature beats: a meta-analysis] [Chinese]. Nan Fang Yi Ke Da Xue Xue Bao. 2010 Nov. 30 (11):2577-80. [Medline].

Chen YH, Lin JF. Catheter ablation of idiopathic epicardial ventricular arrhythmias originating from the vicinity of the coronary sinus system. J Cardiovasc Electrophysiol. 2015 Oct. 26 (10):1160-7. [Medline].

Baldinger SH, Kumar S, Barbhaiya CR, et al. Epicardial radiofrequency ablation failure during ablation procedures for ventricular arrhythmias: reasons and implications for outcomes. Circ Arrhythm Electrophysiol. 2015 Dec. 8 (6):1422-32. [Medline].

Class

Arrhythmia

0

None

1

Unifocal; < 30/h

2

Unifocal; ≥ 30/h

3

Multiform

4A

2 consecutive

4B

≥ 3 consecutive

5

R-on-T phenomenon

Jatin Dave, MD, MPH Part-Time Clinical Instructor, Department of Medicine, Harvard Medical School; Attending Physician, Division of Aging, Department of Medicine, Brigham and Women’s Hospital; Medical Director of Geriatrics, Tufts Health Plan

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Tufts Health Plan, a not for profit organization.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Brian Olshansky, MD Professor Emeritus of Medicine, Department of Internal Medicine, University of Iowa College of Medicine

Brian Olshansky, MD is a member of the following medical societies: American College of Cardiology, American Heart Association, Cardiac Electrophysiology Society, Heart Rhythm Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: On-X Cryolife; Lundbeck <br/>Serve(d) as a speaker or a member of a speakers bureau for: On-X Cryolife; Lundbeck <br/>Amarin – chair DSMB for: Boehringer Ingelheim – national coordinator GLORIA AF.

Jeffrey N Rottman, MD Professor of Medicine, Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine; Cardiologist/Electrophysiologist, University of Maryland Medical System and VA Maryland Health Care System

Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association, Heart Rhythm Society

Disclosure: Nothing to disclose.

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous authors John Michael Gaziano, MD, MPH; Revat Lakhia, MD; and Shivkumar H Jha, MD, to the development and writing of this article.

Ventricular Premature Complexes

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