Treatment of Palpitations Due To Benign PVCs: Potassium, Magnesium and Lifestyle Adjustment

In a previous post, the skeptical cardiologist pontificated on the causes and evaluation of the most common cause of palpitations: premature ventricular contractions or PVCs.

The vast majority of these common extra beats turn out to be benign (meaning not causing death, heart attack or stroke), and most patients with sufficient reassurance of this benignity (often accompanied by significant caffeine reduction), do well. These people usually continue to notice the beats either randomly, or with stress, but they recognize exactly what is going on and are able to say to themselves “there go my benign PVCs again,” and aren’t worried or bothered.

A small percentage of patients that I diagnose with palpitations due to benign PVCs continue to have symptoms.

Part of my initial evaluation involves checking potassium, magnesium, kidney function, and thyroid levels.

Potassium Supplementation For PVCs

Low potassium levels (hypookalemia) have been clearly associated with an increase in ventricular ectopy. Patients who take diuretics like hydrochlorothiazide (HCTZ, often used for high blood pressure) or furosemide (Lasix, often used for leg swelling or heart failure), are at high risk for hypokalemia with potassium levels less than 3.5 meQ/L.

Hypokalemia can also develop if you are vomiting, having diarrhea, or sweating excessively. There are lots of other infrequent causes including excess licorice consumption. The body regulates potassium levels closely, due to its importance in the electrical activities involved in cardiac, muscular and neurological function.

The normal range of potassium (K) is considered to be 3.5 to 5 meq/L , however, I have found that PVCs are more frequent when the potassium is less than 4.

Most of my symptomatic PVC patients with potassium less than 4 find significant improvement with potassium supplementation.  I usually give them a prescription for potassium chloride (KCl) 10-20 meq daily to accomplish raising the level to >4.

An alternative to potassium supplements is ramping up how much
screen-shot-2017-03-02-at-6-18-48-pm screen-shot-2017-03-02-at-6-19-11-pmpotassium you consume in your diet. Most patients I talk to about low K immediately assume they should eat more bananas, but lots of fresh fruit and vegetables contain as much or more K than bananas.

The charts to the right show that a medium tomato contains as much K as a medium banana with a third of the calories. Avocados are a great source of K and contain lots of healthy fat. Yogurt (and I recommend full fat yogurt, of course) is a great source as well.

If you have  kidney disease you are much more likely to develop hyperkalemia, or high K, and you want to avoid these high K foods. Potassium infusions are used as part of a “lethal injection” in executions because extreme hyperkalemia causes the heart to stop beating. (In fact, Arkansas is hurrying to execute 8 men between April 17 and 27 utilizing KCl.  According to “The hurried schedule appears to be an attempt to use the state’s current supply of eight doses of midazolam, which will expire at the end of April. Arkansas does not currently have a supply of potassium chloride, the killing drug specified in its execution protocol, but believes it can obtain supplies of that drug prior to the scheduled execution dates”)

Lifestyle, Stress  and PVCs

It’s probably time I revealed that I have PVCs. I feel them as a sense that something has shifted inside my chest briefly, like my breath has been interrupted, like my heart has hiccoughed. If I didn’t know about PVCs and hadn’t made the diagnosis very quickly by hooking myself up to an ECG monitor in my office, I know I would have become very anxious about it.

I know exactly what causes them: stress and anxiety. And this is the case for many patients. Stress activates our sympathetic nervous system, causing the release of hormones from the adrenal gland that prepare us for “fight or flight.” These hormones stimulate the heart to beat faster and harder and often trigger PVCs.

I rarely get PVCs these days, as the major source of stress in my personal life has gone away. This is also a typical story my patient’s relate: troubling palpitations seem to melt away when they retire or change to less stressful occupations, or as they recover from depression/anxiety/grief related to death of loved ones, divorce or illness.

You can’t always control external stresses, but several factors in your lifestyle are key to managing how those stresses activate your sympathetic nervous system and trigger troubling PVCs.

Dr. Mandrola lists as Steps 5-8 (Steps 1-4 are reassurance) for PVC treatment his “four legs of the table of health”:

: good food, good exercise, good sleep and good attitude. Cutting back on caffeine and alcohol, looking critically at the dose of exercise, going to bed on time, and smiling are all great strategies for PVCs.

Of these four table legs, I consider regular aerobic exercise the most important, and modifiable factor for PVC reduction.  Aerobic exercise improves mood and increases the parasympathetic (the calming component of the autonomic nervous system) activity, while lowering the output of the sympathetic nervous system.

The three factors that I find essential to handling the demanding and stressful job of being a cardiologist: restful sleep, regular, aerobic exercise and lots of love from my eternal fiancee (who also has occasional PVCs!)

Apple Watch trying to get me to breathe (something I ordinarily don’t do). According to Apple (my comments in parentheses) “Mindfulness is a state of active, open attention on the present. When you’re mindful, you observe your thoughts and feelings from a distance (my favorite way to think and feel) without judging them good or bad (even if I’m thinking about robbing a bank?). Instead of letting your life pass you by, mindfulness means living in the moment (a really boring moment) and awakening to experience (or lack thereof). (Apologies to SH :))

Beyond sleep and exercise there is a plethora of techniques that purport to help individuals deal with stress: yoga, meditation, and progressive muscular relaxation, among them.

Apps touting methods for relaxation abound these days.  My new Apple Watch is constantly advising me to engage in a breathing exercise for a minute at a time. I don’t find any of these techniques helpful for me (I haven’t found a good way to shut my brain down without falling asleep), but they may work for you.

Magnesium, Snake Oil and PVCs

Patients will find that the internet is rife with stories of how this supplement or vitamin or herb dramatically cures PVCs.  You can be assured that a sales pitch accompanies these claims and that the snake oil being promoted has not been proven effective or safe. Because symptomatic PVCs like most benign, common and troubling conditions (lower back pain, fatigue, and nonspecific GI troubles come to mind),  are closely related to mood and wax and wain spontaneously; the placebo effect proves powerful. In such conditions, snake oil and charlatans thrive.

Magnesium is enthusiastically hyped on the internet for all manner of cardiovascular problems including PVCs. Even Dr. Mandrola, who I respect quite a lot as an EP doc who promotes lifestyle change and who is definitely not a quack, lists his step 10 for PVCs (apologetically) as follows:

  • Step 10 (a): Please don’t beat me up on this one. Some patients report benefit from magnesium supplementation. I have found it helpful in my case of atrial premature beats. Let me repeat, I am not promoting supplements. Healthy patients with benign arrhythmia might try taking magnesium, especially at night. Don’t take magnesium if you have kidney disease. And if you take too much, watch out for diarrhea.

Most of the internet’s top quacks, however, greedily market and glowingly swear by magnesium.  A Google search for magnesium cardiovascular disease yields 833,000 entries and the first page is a Who’s Who of quackery, including Dr Mercola (strong candidate for America’s greatest quack), Dr. Sinatra (see here, currently in the semifinals for America’s greatest quack cardiologist), NaturalNews and Life Extension (see here). This totally unsupported and dangerous blather from the Weston Price Foundation is often repeated and is typical:

(magnesium) Deficiency is related to atherosclerosis, hypertension, strokes and heart attacks. Deficiency symptoms include insomnia, muscle cramps, kidney stones, osteoporosis, fear, anxiety, and confusion. Low magnesium levels are found in more than 25 percent of people with diabetes. But magnesium shines brightest in cardiovascular health. It alone can fulfill the role of many common cardiac medications: magnesium inhibits blood clots (like aspirin), thins the blood (like Coumadin), blocks calcium uptake (like calcium channel-blocking durgs such as Procardia) and relaxes blood vessels (like ACE inhibitors such as Vasotec) (Pelton, 2001).

Magnesium levels are very important to monitor in hospitalized and critically ill patients, especially those receiving diuretics and medications that can effect cardiac electrical activity.

However, for individuals with normal diets and palpitations due to PVCs, there is scant evidence that it plays a significant role in cardiovascular health.

The MAGICA study looked at supplementation with both magnesium and potassium (in the active treatment group, daily oral dosing consisted of 2 mg of magnesium-dl-hydrogenaspartate (6 mmol magnesium) and 2 mg of potassium-dl-hydrogenaspartate (12 mmol potassium) daily. The dose was chosen to increase the recommended minimal daily dietary intake of magnesium (12 to 15 mmol) and potassium (20 to 30 mmol) by ∼50% in addition to usual diet ) in 307 patients with more than 720 PVCs per hour and normal baseline K and Mg levels.

The patients receiving magnesium/potassium supplements showed a decrease of 17% in frequency of PVCs but no improvement in symptoms.

A 2012 study in a Brazilian journal evaluated magnesium pidolate (MgP) in 60  patients with both PVCs and premature atrial contractions (PACs). The dose of MgP was 3.0 g/day for 30 days, equivalent to 260 mg of Mg elemental.

93% of patients receiving MgP experienced improved symptoms compared to only 13% of patients recieiving placebo. Both PVC and PAC frequency was reduced in those receiving MGP, whereas they increased by 50% in those receiving placebo.

This small study has never been reproduced, and the main results table makes little sense. It would not have been published in a reputable American cardiology journal and cannot be relied on to support magnesium for most patients with benign PVCs or PACs.

Drug or Ablation Treatment of PVCs: Usually Not Needed

A small percentage of my patients require treatment with beta-blockers which reduces the effects of the sympathetic nervous system on the heart. Very rarely, I will use anti-arrhythmic drugs. And every once in a while, very frequent PVCs resulting in cardiomyopathy require an ablation.

However, the vast majority of patients with benign PVCs, in my experience, feel drastically better with a simple non-pharmacological approach consisting of 4 factors:

  • Reassurance that the PVCS are benign
  • Caffeine (or other stimulant) reduction
  • Lifestyle adjustment with regular aerobic exercise
  • Increased potassium intake to keep K >4

Ectopically Yours





28 thoughts on “Treatment of Palpitations Due To Benign PVCs: Potassium, Magnesium and Lifestyle Adjustment”

  1. Since the beginning of the year, I have been experiencing some occasional palpitations. So. last weekend, when I started feeling them again, I used the AliveCor Kardia monitor on my wife’s iPhone to collect an EKG. And sure enough, every time I felt a palpitation, I saw an unusual pattern in the EKG. I then Googled “EKG Images” and found a trace with the same pattern as mine: it was a PVC. Since I follow this blog, I wasn’t alarmed by this information. But, to be safe, my wife made an appointment with a cardiologist here in Atlanta.

    At the doctor’s office, I was subjected to a 12 electrode EKG and then met with the cardiologist. She was impressed with my self diagnosis and confirmed that I did not have to be worried. After a number of questions about my coffee and alcohol intake (yes and yes) as well as my current drug regimen, she suggested I stop taking one of my blood pressure medications (Amlopidine) and start taking a low dosage of a beta blocker instead. She pointed out that this might decrease how strong the PVCs feel when they occur but also added a list of side effects which sounded like white noise until I heard the horrifying phrase “erectile dysfunction.”

    She also prescribed a stress test and ultrasound the following week which, I assume, is all part of the baseline process. Is this standard procedure?

    1. Thanks for your comments, Wally!
      I too am impressed with your utilization of your wife’s AliveCor monitor and self/Google diagnosis.
      I don’t view moderate alcohol consumption as a significant trigger of PVCS you will be happy to hear.
      Amlodipine is a direct dilator or arteries and as such can cause a reflex increase in the heart contractile function and general sympathetic tone. This may make patients more aware of their heart beat in general and of PVCS in particular.
      A switch to another antihypertensive might improve the frequency of the PVCs or make you less aware but you should understand that this is not improving your cardiovascular risk profile and would only be for symptoms.
      There is strong evidence that for hypertension, beta-blockers are associated with a higher stroke risk than other BP meds. I have a theory on why this is which I will write about some day. Beta-blockers also have ED, sleep disturbance, depression, fatigue, and asthma as potential side effects.
      Diuretics are very effective as a second agent for BP. They can lower K however so you would need to monitor your K and keep it over 4 by diet or supplements.
      Dr. Pinski tweeted me that 8 ozs of V8 contains 960 mg of K by the way.
      The tests you describe are appropriate as long as they are read by an expert and not “botched” yielding false positives and dangerous down stream testing.
      Do not have a nuclear stress test.!

  2. I have Premature Atrial Contractions with occasional AFib, does the PVC information apply to PAC’s? I take 36mg of Metoprolol & a low dose asprin daily. I stopped alcohol & cut back on caffeine, but still have the PAC’s, although not as bad. You give such great information that is hard to get out of my cardiologist.

    1. Mary,
      Premature atrial contractions are similar to PVCs except that the extra beats are coming from the atria. They are very common in the general population of individuals with normal hearts and most people don’t feel them or are not as bothered by them as much as PVCs. With a PAC although the heart beats prematurely, the normal sequence of electrical activation (first atrium, then ventricle) and the normal electrical conduction through the ventricle is preserved, thus the hemodynamic consequences are much less than that of the PVC. There is less of reduction in how much the ventricles pump and less drop in BP. Also, the pause after a single PAC is less than with PVC.
      Whereas I see lots of patients symptomatic from PVCs, I have only a few with isolated PACs who are symptomatic. PACs can be strung together with brief bursts of what I was taught to term “benign atrial tachyardia,” in which case symptoms are more likely

      It’s probably reasonable to follow all the measure I recommend for PVCs to someone with PACs
      There may be more of a role for calcium channel blockers over beta-blockers for symptomatic PACS.
      I usually think more of lung disease in the patient with lots of PACS.
      I hope this helps

  3. Hi, earlier this year I began to experience quite strong heart palpitations followed by feelings of light headedness which in four instances over 3 days resulted in fainting. I was admitted to hospital and diagnosed with long qt syndrome and put on 20my daily of nadolol (ex. Corgard). My qt.interval was ‘just’ outside normal timing according to my cardiologist and has since fully normalised. Do you have any knowledge in this are area of alternate ways of managing this or any advice for alternate treatments/foods to increase together with the beta blockers?

    1. I don’t have any special expertise or experience in Long QT syndrome. However, i do think it imperative that you undergo prolonged monitoring to fully document what your heart rhythm is when you experience the fainting.

  4. Hi Dr. Haven’t wrote in awhile on here. Now for pacs that run into afib do you prefer a beta blocker such as propanolo as a pip approach or just an antidepressant to help as well if sometimes they are caused from stress? I hear Prozac was good but also read online it provokes afib. What do you think along the lines for these meds?

  5. Doc – awesome site. Just discovered it and I’m methodically reading it all.

    I apologize if this has been answered elsewhere already, but wondering why you advise to NOT get a nuclear stress test.

    Thank you,

    Rob in Atlanta

    1. If your only symptom is palpitations and it turns out to be from PVCs then it is highly likely you have a normal heart and have no high-grade blockages of your coronary arteries.
      In this situation we do want to confirm normality with something like a stress echo which has good specificity.
      Good specificity means the test is unlikely to be read as abnormal when there is no problem.
      Stress nuclear tests, especially if read by radiologists and inexperienced cardiologists have a very high rate of false positives and low specificity. Thus, most of the abnormal nuclear tests for someone with PVCs are not indicative of blocked arteries.
      Then you end up going down a path of invasive testing with potential complications and with the potential for getting a stent you didn’t really need.
      On top of that stress nuclears are more expensive and involve quite a bit of radiation.

  6. Great site and very informative! I began having frequent PVCs six months ago and went to the emergency room twice during that time, convinced I was having heart failure. However, no test my cardiologist threw at me (Stress Test, Holter Monitor, Chest X-Ray, Echocardiogram) revealed Afib or anything structurally abnormal, other than semi-frequent PVCs/PACs. The stress issue came up frequently, but in my opinion that is just a specious attempt to offload the problem from physiology to psychology. I didn’t need relaxation or yoga, I needed to correct a physical imbalance. Dietary changes (treating the problem like a gastrointestinal/acid reflux problem rather than a cardiovascular problem) and reduced alcohol/caffeine certainly helped reduce PVCs for me, but when I began taking 100mg of magnesium four times a day after reading about it on a forum online, the problem almost completely vanished. Since I began taking magnesium daily my health and well being have ramped way up, and the PVCs have been pushed way down to an occasional blip. I’m glad to see professional sites like this addressing the issue, but from reading widely in the Internet, it seems a lot of people are having this problem and their doctor’s simply do not know how to treat it.

    1. Peter,
      Thanks for your kind words and comments.
      I tried to address the data on magnesium in the post.
      I do think there are some symptomatic PVCers who will benefit from magnesium but this is rarely due to a true magnesium deficiency. I worry about promoting magnesium too enthusiastically due to the many snake oil salesmen hyping their proprietary brand of magnesium for everything that ails everyone.
      What type of magnesium are you taking and why four times daily?
      Physiology and psychology are closely intertwined by the sympathetic nervous system-it’s very hard to separate them.
      Of the tests thrown at you I can find no reason for a chest X-ray.
      Dr. _P

  7. I have noticed the weird sensation that you describe in your chest that you are attributing to PVC’s. I have checked my pulse when I feel this sensation and I have 2-3 second pause before it beats again. It is a regular beating pattern with pauses. When I take magnesium on a regular basis I seem to have fewer episodes. I know that low magnesium can be a cause of low potassium. Could it be that when I take the magnesium it is actually improving the potassium level?

  8. Great information. Thank you. Overall I’m not too concerned about my PVCs. For about a year I’ve been relatively free of them. Occasionally I will feel a few in a row while at
    my desk or laying down at home. Maybe once every couple of weeks. I always feel them when they come. However for the last few days I’ve had episodes that last an hour near bed time or when I wake up in the morning.

    Tonight they seem more frequent. It’s been three hours on and off with 10-20 a minute. Is it possible for PVCs to be benign at this duration or frequency? Assuming there are no underlying issues causing PVCs, what duration and frequency would you feel warrent a ER visit or the next available cardiology appt.?

    1. Darsen,
      It is possible for PVCs to be benign at that frequency and duration. Assuming that your heart is structurally normal and that your current symptoms are definitely due to PVCs there is little to gain from an ER visit. However, those are significant assumptions and things change with the heart, so, in general the safest thing to do for any new and worrisome symptom is to call 911 for an ambulance. I’m not advising you do that , just commenting for that situation in general.
      For my patients, I encourage them to call me with any questions or concerns, and if I received a call from a patient describing what you are describing I would (depending on the time since our last evaluation and other factors in their prior history) likely have them wear a 24 hour monitor and check potassium, magnesium and thyroid levels and see them in office after seeing the results.

      1. Turns out for my situation, I had been aggressively treating Psorisis with a lot of Mometasone Furoate… this prednisone derivative seems to be part of the cause…. along with stress…. which typically causes psoriasis issues for me.

        I have given you articles to my PA as he tells me a lot of his patients come in for PVC.

        Thank you for the peace your articles give…

      2. Thanks for your comments!
        Oral steroids cause multiple metabolic changes including changes in potassium and could definitely influence PVC frequently
        Topical steroids are designed to have minimal systemic uptake but it is possible a high potency topical steroid could have systemic effects.

  9. My Dr. referred me to your website after my frequent complaints of pvcs. After reading this page I asked my Doctor to check my potassium levels, and guess what….they are low! They have always been low, and currently they are the highest they have ever been at 3.9. I picked up some 99mg potassium citrate today in hopes of getting my levels higher, and ultimately eradicating these darn pvcs. My question is this: the pharmacist told me to take 1 pill, every 2 days. Is that enough to get my levels back up?

    1. Dannica,
      I usually prescribe potassium chloride (KCl) for patients with low potassium that can’t increase it by eating more foods with potassium.
      Typically we start with 10 Meq. Potassium citrate 99 mg contains 2.5 meq of elemental potassium (divided 99 mg potassium by the atomic weight of potassium 39). So to get 10 meq you would take 4 of those potassium citrate tablets. You may need more or less than this. I am presuming your doctor has verified that your kidney function is normal. The only worry with potassium supplementation is in patients with kidney dysfunction where levels can get too high if supplemented. Levels should be rechecked after a week of supplementing because everyone responds differently.

  10. Thank you for this. I have daily pvcs and have recently had a normal echo. I’m interested about the magnesium supplements and am wondering if you can recommend any? I had a stressful event a few years ago and my sympathetic nervous system seems to have gone into overdrive since! I’m also sure it’s linked to upper GI issues and gas! Any comments on gastro ailments and pvc’s? Thanks

    1. There’s a variety of magnesium supplements and a ton of snake oil salesmen hawking and trying to support their own particular brand.
      In the medical field we tend to prescribe 400 magnesium oxide and we see levels come up with that nicely.
      Since each individual reacts differently I suggest you find a cheap OTC version of magnesium that works for you.

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