Are Your Palpitations Due to Benign PVCs?

If you feel your heart flip-flopping, then you are experiencing palpitations: a sensation that the heart is racing, fluttering, pounding, skipping beats or beating irregularly.

Often, this common symptom is due to an abnormal heart rhythm or arrhythmia.

The arrhythmias that cause palpitations range from common and benign to rare and lethal, and since most individuals cannot easily sort out whether they have a dangerous or a benign problem, they often end up getting cardiac testing or cardiology consultation.

The most common cause of palpitations, in my experience, is the premature ventricular contraction, or PVC (less commonly known as the ventricular ectopic beat or VEB).

Premature Ventricular Contractions-Electrical Tissue Gone Rogue

The PVC occurs when the ventricles of the heart (the muscular chambers responsible for pumping blood out to the body) are activated prematurely.

This video shows the normal sequence of electrical and subsequent mechanical activation of the chambers of the heart.

To get an efficient contraction, the electrical signal and contraction begins in the upper chambers, the atria, and then proceeds through special electrical fibers to activate the left and right ventricles.

Sometimes this normal sequence is disrupted because a rogue cell in one of the ventricles becomes electrically activated prior to getting orders from above. In this situation, the electrical signal spreads out from the rogue cell and the ventricles contract out of sequence or prematurely.

This results in a Premature Ventricle Contraction.

labeled-pvc
p waves represent depolarization and activation of the atria which are followed normally after120 to 200 milliseconds by the QRS complex which represents activation of the ventricles. The PVC (inside red circle) is wider and weirder and disrupts the regular interval between beats (green lines).

I recorded the above AliveCor tracing in my office on a patient who suffers palpitations due to PVCs (we’ll call her Janet).

The wider, earlier beat (circled in red) in the sequence is the PVC. The prematurity of the PVC means that the heart has not had the appropriate time to fill up properly. As a result, the PVC beat pumps very little blood and may not even be felt in the peripheral pulse. Patients with a lot of PVCs, say ocurring every other beat in what is termed a bigeminal pattern, often record an abnormally slow heart rate because only one-half of the heart’s contractions are being counted.

While recording this, every time Janet felt one of her typical “flip-flops,” we could see that she had a corresponding PVC and the cause of her symptoms was made clear.

There is a pause after the PVC because the normal pacemaker of the heart up in the right  atrium (the sinus node) is reset by electrical impulses triggered by the PVC.. The beat after the PVC is more forceful due to a more prolonged time for the ventricles to fill and  Consequently, most  patients feel this pause after the PVC rather than the PVC itself,

PVCs are common and most often benign. I have patients who have

ECG from 70 year very vigrous man who had 20 thousand PVCs in 24 hours. Every third beat is a PVC (green arrow)
ECG from 70 year old very vigorous man who had 20 thousand PVCs in 24 hours. Every third beat is a PVC (green arrow PVC, blue arrow normal QRS.)This patient feels nothing with his frequent PVCs. He has had them probably lifelong and definitely for the last 10 years without any adverse consequences.

thousands of them in a 24-hour period and feel nothing. On the other hand, some of my patients suffer disabling palpitations from very infrequent PVCs. From an electrical or physiologic standpoint, there seems to be neither rhyme nor reason to why some patients are exquisitely sensitive to premature beats.

How Do I Know If My PVCs Are Benign?

My patient, Janet, is a great example of how PVCs can present and how inappropriate or inaccurate heart tests done to evaluate PVCs can lead to anxiety and unnecessary and dangerous subsequent testing.

A year ago,  Janet began experiencing a sensation of fluttering in her chest that appeared to be random. Her general practitioner noted an irregular pulse and obtained an ECG, which showed PVCS. He ordered two cardiac tests for evaluation of the palpitations: a Holter monitor and a stress echo.

A Holter monitor consists of a device the size of a cell phone connected to two sensors or electrodes that are stuck to the skin of the chest area. The electrical activity of the heart is recorded for 24 or 48 hours, and a technician then scans the entire recording looking for arrhythmias while trying to correlate any symptoms the patient recorded with arrhythmias. The Holter allows us to quantitate the PVCs and calculate the total number of PVCs occurring either singly or strung together as couplets (two  in a row), or triplets (three in a row.)

Janet’s Holter monitor showed that over 24 hours her heart beat  around 100,000 times with around 2500 PVCs during the recording.  Unfortunately, the report did not mention symptoms, so it was not possible to tell from the Holter if the PVCs were the cause of her palpitations.

A stress echocardiogram combines ultrasound imaging of the heart before and after exercise with a standard treadmill ECG. It is a very reasonable test to order in a patient with palpitations and PVCs, as it allows us to assess for any significant problems with the heart muscle, valves or blood supply and to see if any more dangerous rhythms like ventricular tachycardia occur with exercise. If it is normal, we can state with high certainty that the PVCs are benign.

Benign, in this context, means the patient is not at increased risk of stroke, heart attack, or death due to the PVCs.

In the right hands, a stress echocardiogram is superior to a stress nuclear test for these kinds of assessments for three reasons:

-Reduced rate of false positives (test is called abnormal, but the coronary arteries have no significant blockages)

-No radiation involved (which adds to costs and cancer risk)

-The echocardiogram allows assessment of the entire anatomy of the heart, thus detecting any thickening (hypertrophy), enlargement  or weakness of the heart muscle, that would mean the PVCs are potentially dangerous.

Unfortunately, my patient’s stress echo (done at another medical center) was botched and read as showing evidence for a blockage when there was none.  An invasive and potentially life-threatening procedure, a cardiac catheterization was recommended.  Similar to the situation I’ve pointed out with the performance and interpretation of echocardiograms (see here),  there is no guarantee that your stress echo will be performed or interpreted by someone who actually knows what they are doing.  So, although the stress echo in published studies or in the hands of someone who is truly expert in interpretation, has a low yield of false positives, in clinical practice the situation is not always the same.

Given that Janet was very active without any symptoms, she balked at getting the catheterization and came to me for a second opinion. I felt the stress echo was a false positive and did not feel the catheterization was warranted. We discussed alternatives, and because Janet needed more reassurance of the normality of her heart (partially because her father had died suddenly in his sixties) and thus the benignity of her palpitations/PVCs, she underwent a coronary CT angiogram instead. This noninvasive exam (which involves IV contrast administration, and is different from a coronary calcium scan), showed that her coronary arteries were totally normal.

lad-ccta
Images from Janet’s coronary CT angiogram showing the left anterior descending (LAD) coronary artery coming off the aorta. The LAD (and her other coronaries) were totally free of any plaque build-up.)

Benign PVCs-Treatment Options

Once we have demonstrated that the heart is structurally normal, reassurance is often the only treatment that is needed.  Now that the patient understands exactly what is going on with the heart and that it is common and not dangerous, they are less likely to become anxious when the PVCs come on.

PVCS can create a vicious cycle because the anxiety they provoke can cause  an increase in neurohormonal factors (catecholamines/adrenalin) that may increase heart rate , make the heart beat stronger and increase the  frequency of the PVCs.

Some patients, find their PVCs are triggered by caffeine (tea, soda, coffee, chocolate) or stress, and reducing or eliminating those triggers helps greatly. Others, like Janet, have already eliminated caffeine, and are not under significant stress.

Since I’m already over a thousand words in this post, I’ll discuss treatment options for these patients with benign PVCs who continue to have troubling symptoms after reassurance and caffeine reduction in a subsequent post.

Prematurely Yours,

-ACP

 

10 thoughts on “Are Your Palpitations Due to Benign PVCs?”

  1. I find that monitoring my blood pressure can be problematic in the midst of PVCs. If one of those forceful follow-up beats occurs as the cuff is deflating, it can register as a quite high systolic anomaly.

    I believe it’s been shown in flip-floppers that longer monitoring than a holter allows for (such as the two-week Zio Patch) finds more occasional and possibly consequential arrhythmias such as brief atrial fibrillation runs.

    How about PACs?

    1. Good observations, Jeff!
      If you look at continuous pulse pressure monitors you will definitely see a drop in the systolic blood pressure with the PVC and an increase in the systolic BP on the beat afterwards (post-extrasystolic potentiation is the medical term). Depending on the monitoring technique this could give you artifactually high systolics and artifactually low diastolics. I don’t know if this has been systematically studied.
      I purposefully avoided talking about longer term monitoring in this post but if time permits will talk about monitors like the Zio (which I am using a lot now) which i think are excellent for documenting transient and asymptomatic atrial fibrillation.
      I also purposefully avoided talking about the little brother of PVCS, the premature atrial contraction or PAC. PACs are very common in normals, usually asymptomatic and almost always benign. They are more associated with lung disease than PVCs. Whether they presage afib is not clear.

  2. Excellent read for the layman. I look Forward to more. I’m an atrialflutter Patient and wondered about this for sure. 😊 thanks so much for helping me to Understand this!

    Sent from my iPhone

    >

  3. Many years ago I suffered from very noticeable symptoms of PVCs for a few years, greatly affecting my wellbeing. They were brought on by a trauma followed by lack of sleep and stress and interestingly, made worse by foods with sulphur dioxide. Fortunately after years of annoyance, they did go away when a combination of reassurance from a cardiologist, stress management, a better unprocessed food diet supplemented with magnesium (mine was in the low normal range) and B12. I had looked into ablation but as a last resort, luckily didn’t need it. Caffeine had no effect either way, and anxiety made it much worse as you describe.

  4. I also suffer from PVC’s and have good luck in minimizing them. I take a powdered form of L-Arginine and a magnesium vitamin. This combination seems to keep them at bay. My research has indicated that most men over 50 have a shortage of Magnesium, while the L-Arginine adds NO (Nitric Oxide) to the blood vessels.

  5. Hi Dr. Anthony,

    I enjoyed reading your post. I have been looking all over the internet to help ease my stress/anxiety from my Pvcs. Internet searching can be very good… or verrry bad for anxiety.

    I am a 32 year old man, healthy and active, and have been dealing with frequent PVCs for the past 6 months. I would first get them after drinking some form of caffeine like coffee or a coke. I would only feel a flutter or 2 for a few minutes..then they would leave. I stopped drinking caffeine for good and I didn’t have and episode for another 6 months or so.

    This past Christmas, I accidentally had a whiskey drink with a coca cola (not thinking about the caffeine). The next day I had multiple pvcs which increased my anxiety(which then seemed to make the pvcs even worse). This became a daily thing after that. Almost to the point that I had to accept it as my normal heart rhythm. Day after drinking alcohol, now seems to make them more noticeable.

    Electrolyte blood tests came back normal. I don’t have any side effects from them. I feel 100% normal. I got the EKG done and they said that they definitely are PVCs. But everything is normal between them. I did a 48 hour Holter, and it came back with 36,000 beats in 24 hours. That number has scared the wits out of me. They were normal individual PVCs with no dangerous signs of v-tach. I had an ECHO done and everything came back normal. I’ve read that some docs say tens of thousands of pvcs are ok and no need to stress. I’ve read that 20% or more pvcs can lead to more serious problems like cardiomyopathy.

    My doctor prescribed me 20 mg nadolol and said due to the high amount, I could eventually get cardiomyopathy if not treated. I wasnt thrilled on how it made me feel after a day (sluggish, kinda heavy in chest area and my home blood pressure test said I had 110/40. Although I didn’t feel faint or dizzy) so i didnt resume taking it. How many years does it take to have the effects of cardiomyopathy from palpitations?

    Right now I am trying to figure out how to lessen the pvc load naturally through stress and anxiety reduction. Is this possible? I have been known to be a “worry wart” so to speak..and have had hyperhidrosis for years. Almost like an unconscious anxiety that has crept up on me to cause pvcs. I almost feel that just being prescribed a light anti-anxiety might do wonders. I just dont know. I am thinking about buying my own Holter monitor to see what works and what doesnt.

    If you have any advice, I would greatly appreciate it. Thank you!

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