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 (hypokalemia) have been clearly associated with an increase in ventricular ectopy aka PVCs.
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 potassium 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 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 deathpenaltyinformation.org: “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 fiancée (who also has occasional PVCs!)
Beyond sleep and exercise, there are 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
-ACP
103 thoughts on “Treatment of Palpitations Due To Benign PVCs: Potassium, Magnesium and Lifestyle Adjustment”
Just replying to say I think my PVCs are related to the Covid vaccine. I got the JJ shot early on and then in November 2021 I got the Pfizer shot. A few weeks later I started noticing heart symptoms like thumping, racing, skipping a beat, light headedness, feeling short of breath. My pulse was always within a normal range but sometimes I’d have a hard time sleeping feeling so uncomfortable. A one week heart monitor diagnosed me with PVCs. At the time my primary doctor said we could discuss medication but I felt they had improved. Now months later they are becoming more bothersome again.
Thank you for this. I am (was) a very healthy semi-athlete in his early 50s who worked out, lifted, BJJ, etc. Due to a series of events related to the political climate in the last two years, I was required to get the Covid-19 vax for work. I received the J&J on September 2, 2021, and the very next day, I started to have (what have now been determined to be) PVCs, as well as pulsitile tinnitus. My heart also races when I lay down and 6 out of 7 nights, I do not get sufficient sleep, in hours or depth. My pulse has also been running high (mid 90s when used to be mid 70s during the day).
A CT scan and blood work up revealed no actual heart damage (echocardiogram pending), but I did show low potassium (3.7). I have been on blood pressure meds now a couple months (Amlodopine) and my doctors just put me on Metoprolol for my PVCs and heart rate. It’s been just a day but it seem to help last night. She said she is going to switch me to beta blockers for my BP (If I understand correctly).
I realize people have a lot of stock in denying the obvious: I was fit, without any heart racing or PVCs, then got the vax and it all started. I had NO IDEA any of this was a potential side effect of the J&J (only that blood clotting was a rare thing, usually for women). Now it seems others have the same issue.
I continue to work out, cut out coffee and hope and pray for healing. It’s been a nightmare. Sorry for all of us dealing with this.
Which, if any, of your treatment recommendations (e.g., potassium) would also apply to PACs? Several years ago I experienced what I thought were PVCs, in distressing and disruptive frequency, but they turned out to be PACs. My cardiologist had nothing to offer but reassurance and a beta blocker prescription, which he cautioned was not likely to help (and eventually, a treadmill stress test, which was normal but detected PACs). Since I am a long-term user of proton pump inhibitors, my first thought was low magnesium, but my serum magnesium was normal. I then read that serum magnesium can be a poor indicator of cellular magnesium levels and increased my magnesium supplementation. Over the next several weeks the PACs completely disappeared. However, now, several years later, they have returned, and increased magnesium supplementation is not helping. Some suggest potassium supplementation might help. However, here is a study that found higher circulating potassium levels are associated with higher prevalence of PACs (but lower prevalence of atrial fibrillation): https://pubmed.ncbi.nlm.nih.gov/32451276/
(Note: I first asked about this study using your appointment-or-inquiry form, which I now realize was probably not its purpose. Sorry for the duplication.)
Hi Dr. Pearson. Thank you very much for all of the information on this blog and your responses in the comments. It is sure helpful.
I am having a hard time finding a solid answer to what is going on with me as it relates to my PVC’s. I’ve been seeing a cardiologist once a year for the last few years and I am currently waiting to see an electrophysiologist. My main issue is that I seem to get tons of PVCs while I am playing ice hockey, so many to the point where I am ready to quit playing because I just cannot enjoy myself while it’s going on. I’ve been getting PVCs on and off for 30 years now (I am currently 46) and I have been playing hockey that entire time at a rec/beer league level. I keep in pretty good shape, work out 5-6 times per week in addition to 2x per week hockey and I constantly have very good bloodwork/cholesterol as recent as last December.
The PVC’s seem to come on when I am anxious about them and over the years I’ve had major anxiety about them and health anxiety overall. Once I am on the ice and start getting them, I get really anxious and no doubt start hyperventilating while I’m out there trying to play but I can’t tell because I’m already breathing hard due to the pace of the game. Sometimes I feel like there are multiple PVC’s in a row but I’m pretty sure they are not actually happening in a row but my heart is beating so fast that it’s hard to tell. And of course, when I have worn a monitor to see how they how my heart reacts while I am playing, they simply don’t happen at all. My cardiologist has told me that he can’t find anything wrong with my heart and says in his opinion the extra beats are totally benign and anxiety-driven, but when they happen with such frequency while I am playing, it genuinely terrifies me.
When it happens, it feels basically like this: beat, beat, PVC, beat, PVC, beat, beat, PVC, beat, beat, PVC, beat, etc. when my HR is at 170-180. They then calm down a bit when I’m on the bench in between shifts as my HR recovers, but they are still present. The fact that they didn’t occur when I actually wore the monitor makes me think it’s more anxiety than anything, but like I said, it is terrifying when it happens and I can’t concentrate on the game on the ice or have fun in any way.
In your opinion, is it dangerous to continue playing if that is happening? My Cardiologist doesn’t seem to think so, I pass his treadmill test with flying colors each time I do it (and very minimal PVC’s, if any) and he said I can keep playing hockey as long as I feel I’m able and want to play.
I’ve been taking Magnesium Taurate for a week now and have been off caffeine for two weeks but still continue to get occasional PVC’s throughout the day and night, which of course happen more and more as I think about them. If I distract myself with work or other things, they seem to calm down and disappear for the most part.
Sorry for the long winded story. I would love to hear what you think, if you have the time.
Thank you,
Brian
Brian,
My approach to a patient with PVCs during exertion is similar to the one I describe in my blog articles.
I want to make sure 1)the left ventricle is normal (usually by echocardiogram) and there is no ischemia/blocked coronary arteries (typically by a stress test). If patient does well on on a maximal treadmill stress test with no high risk findings I clear them for continued activity.
A recent JACC article concluded ” High-grade PVCs occurring during the exercise phase were not associated with increased risk. Recovery PVCs did not improve 20-year cardiovascular mortality risk discrimination beyond clinical variables.”
https://www.jacc.org/doi/10.1016/j.jacc.2021.09.1366
I think your cardiologist is correct. I would be wary of any procedures recommended by the electrophysiologist.
Given the exercise and anxiety triggers for the PVCs I would consider trial of beta-blocker.
Dr. P
Hello Dr Pearson,
There are several forms of Magnesium but which is the best to lesson the PVC’s or eliminate them? There is Magnesium Malate, Citrate, Taurinate, Bisglycinate, Orotate, Carbonate, Citrate. Which one of these targets the PVC’s the best?
Thank you
Aaron,
Your question prompted me to finish a post I had started a long time ago. Just published on magnesium
Dr. p
Hello, I don’t know if you will still reply to this but it is worth a shot. I was diagnosed with PVCs in 2014 and got reassurance from my cardiologist in 2019 with an Echo and stress test. I passed with flying colors and everything was fine, that helped me a bit but my current PVCs have been really bad while running and exercising. That was the case previously too but with reassurance 3 years ago my anxiety has got the best of me again lol. I should still be good, right? I am 34 and had everything normal 3 years ago. Thanks
this should answer your question
https://theskepticalcardiologist.com/2018/04/28/the-skeptical-cardiologist-answers-good-questions-retesting-for-symptomatic-benign-pvcs/
Thank you so much for replying to me! Love your stuff!
I am so grateful that you have provided this sight and I have learned so much from it and appreciate your respnse to my post regarding the Bystolic. After careful reading on your recommendations, I asked my cardio NP to write an rx for it. I have been on 2.5mg for about 20 days now and don’t seem to get much relief of the palpitations. I have some morning wonkiness several hours after taking the dose but bp runs 136/68 or there about but heart rate can go as low as 50. The first week or so that I began Bystolic, I thought it was working pretty well but as the days go on, I am having second thoughts. I have read that it might take up to 30 days for optimal results. Do you think I need to give it more time?? Also..I was diagnosed with Fibromyalgia and CFS 12 years ago and have found since then..all my life really..I am very sensitive to medications and wondering if beta blockers just are not for me. In the past, I have tried Diltiazem, Metoprolol (together and apart) Sotalol, Propafanone and was given an rx for Flecanide but after discovering the Propafanone was a proarrythmic was advised not to take it. I have been told by three doctors that I should “live with them” but I am impatient to feel better and get some some semblance of a life back. I am so weary of trying and failing on so many medications. I will see my cardiologist in June but would so appreciate any helpful information from you regarding my problem. Thanks for any advice you can give me.
Gaylene,
Sorry for the delayed response. If you have a structurally normal heart (normal left ventricle and no significant coronary artery disease) then you should be OK to take flecainide.
Dr. P
Hello Dr Pearson. I have been following your blog for months now and have learned so much. I have had palpitations for 30 years but within the last two years they have been more troubling. I am a 71 year old woman with fibromyalgia and fatigue. I have had all the required heart tests; echo, stress test blood work, etc. this year and everything came out okay. I have seen two ep’s besides my regular cardiologist and his np. No one can zero in on why I’m having these and I have a boatload of drugs that have not worked..ccbs, propafenone, sotalol and metoprolol. I have practically made a career out of reading researching, etc the proper drug for these annoyng and stressful things. I read your latest info regarding Bystolic and asked my doctor for an rx and have been on 2.5mg for two weeks now. I have noticed a few days with hardly any but the last week has been miserable with more palps than I can count (though recorded on the Kardia mobil). I just read a past column where you advised against treating pvc’s with beta blockers due to possible stroke and wondering if these recommendations still hold true for Bystolic. The only side effect is a low resting pulse of 52 to 55 some fatigue and blood pressure goes up a bit in the afternoon. I would like to give this med a chance but am a little puzzled as to where you stand on this particular drug. Thanks so much for this valuable and informative site.
Gaylene,
thanks for your kind comments on my site.
I have mentioned in the past that beta-blockers may make it hard for patients to know if they are in afib or not and thus might increase their risk of a silent stroke. This applies primarily when we are looking at BP drugs. If you have another reason to be on a beta-blocker (like PVCs) then I am fine with them.
In particular as you frequently monitor your heart by Kardia you will know when you are in atrial fibrillation right away.
Bystolic is a very reasonable drug to try for your symptomatic PVCs.
Dr. P
In January of 2021 I moved into a nice apartment with a nice view and a large balcony for plants and outdoor living. Plus off to my right a not so nice view of a cell tower on an adjacent building very close to me. I am less then 100 feet from the tower and about 25 feet below its height so this puts me in a pretty direct line.
In May of 2021 I started to develop PVCs and in December 2021 I still have them. The PVCs do come and go in both frequency of beats and various times during the day.
I’m wondering if this might be a source of my PVCs. I have tried searches but most of the time I come up with dubious information. I do see some National Institutes of Health studies and from a layperson’s view there just might be some connection. But I also find a lot of junk online as well.
Is this something I should consider pursuing?
I do have coronary artery disease and have had stents placed in my arteries. I have not brought this up with my cardiologist yet but his assessment of my PVCs are they are benign and he treats them with calcium channel blockers. (I cannot tolerate beta-blockers) On my next appointment I will ask if this might be an issue.
I am a 66 year old male in reasonably good shape. I exercise a 3 times a week including 30-40 minutes of treadmill time. I am generally an active person.
Jeff,
I am unaware of any studies suggesting cell towers might cause pVCs. That being said, the looming presence of the tower could be affecting you psychologically, increasing sympathetic tone in the body and worsening the PVCS.
Dr. P
Hello, over a year ago I underwent an “successful” ablation for SVT AVNRT. I have not had another SVT episode since, however I started to notice PAC’s for the first time. I am 25 years old, echocardiogram came back good. My heart is structurally fine. Stress, diet, etc definitely trigger my PACs. I will go weeks and even up to a month sometimes without noticing any PACs. And then I will go days or a week straight and have thousands of PACs a day. Potassium and magnesium supplementation seem to help but they can be very worrisome. Any advice or recommendations? My EP says there is nothing to worry about but it’s easier said then done. Thanks
Lee,
I suggest you read my post on premature atrial contractions.
Dr. P
This was an informational read for me..
I suddently felt lot of palpitations and went to the urgent care, they did EKG and noticed irregular heart beat and said its PVC and asked to follow-up with cardiology. At the cardiology the Dr said it looks benign and suggested 2 week monitoring and echo cardiogram, so the diagnosis will take a month with all the appointment availability, my potassium level is 3.6 but he suggested that I have magnesium chloride. I got my magnesium levels tested and it shows as 2.1 (range 1.5 to 2.5) but I also read a lot about how blood test is not conclusive for magnesium, should I still take the magnesium chloride supplemnt ?
I notice my symptoms are more when I am resting or sitting down for work. When I am walking or doing work when on the feet I dont feel it as much.
I have a very disturbed sleep as well. The pounding it my heart keeps stressing me out even more.
Would like your advice and suggesstions please. Also should I take magnesium chloride (i think slow mag) also how long does it take to increase potassium levels ? I am eating 1/2 avacado ,1 banana , 1.2 cup full fat greek yogurt to get my levels up
Please advse
Thank you so much
ancilla,
See my recent post on magnesium supplements.
dr. P
Hi, My holter test said 22 percent pvcs. Normal echogram. I have a resting heart rate of 64 and when put on atenolol it dropped by heart rate in the 40s so I am not able to take beta blockers. I was concerned because I read that lots of pvcs can lead to a weaken heart. My Dr. said, not to worry. I am taking magnesium and thinking of adding in some taurine as a study I read said they can stop pvcs?
This is one of the most resourceful and accurate sites I have found regarding PVC’s. I want to profusely thank you for taking the time to explain to long time sufferers like myself the nature of PVC’s.
I am a 50 year old male who has had benign PVC’s since my twenties. I did not truly understand or even identify PVC’s until an appointment with an electrophysiologist about 10 years ago! He told me they were benign PVC’s. As a matter of fact my first cardiologist visit in my twenties diagnosed me with a heart murmur only to be told by another later on that there was no murmur.
So needless to say it has been a long road to getting reassurance. It is also important to note that during that period I was diagnosed with an anxiety disorder which is a contributing factor. I have even been prescribed Ativan and Inderal but am reluctant to use them.
Worse was not knowing what was actually happening with my heart created even more anxiety and made me borderline agoraphobic.
It is so relieving to know there many other people who experience these symptoms and to find a website where someone can learn so much. If I can share what works for me:
1. Reassurance is key. And that part is still a work in progress as I have to repeatedly un-condition myself to not react anxiously.
2. Sleep. At least 8 good hours.
3. Stress management. If I don’t work on this the first two don’t matter.
The one question I have is: Why do I feel like my PVC’s originate from my abdomen sometimes like a spasm?
I feel the exact same way! Like my PVCS originate my abdomen!!! Did you ever figure that out? I’m on omeprazole now because I assumed GERD. Getting checked for H Pylori. Have chronic constipation issues. PVCs happen when I slouch mostly. There’s a very sensitive are in my stomach area that if pushed upon by accident or pant is a little tight, it triggers PVCs
Joanne,
I have a patient whose atrial fibrillation was triggered by similar factors.
Dr. P
Dear Anthony,
Congratulations on the terrific blog. This article has been an especially interesting read as I’m myself affected by PVCs, but its inquisitive and rational tone would make it enjoyable anyway (I’m a scientist myself, even if not in the medical field).
The question – if any – is at the bottom of this longish rant. The rest is mere background.
I just come back from the latest cardiologic assessment and perhaps I’m writing more to express myself (and my concern) than to request an answer: also, I understand the volume of comments and mails is high and it’s difficult to formulate an opinion – not to say a judgment – via the internet.
I’ve kept my heart checked since very early, let’s say when I was 14 (currently I’m 32) as I have been doing sport quite intensely and a medical clearance was required to participate in competitions. Never found an issue or even the trace of an issue, with only one exception: once they suspected I had a dilated heart after an X-ray taken to the chest bones. They then prescribed a Doppler ultrasonography with the result: “the heart is big but still within the range of normal”. Maybe the fact that I had the healthy lifestyle of a sportsman helped – never smoked, drink rarely and with moderation except for that occasional wedding party/last year’s eve).
Still I wondered about the state of my heart sometimes, as I have a quite marked and unfortunate family history of heart events – maternal grandpa died of a heart attack in his sixties, paternal uncles all with some by-pass or stent and some even came close to a bad end out of a sudden when relatively young. I had some sparse episodes of fainting, I can count 3 all my life long – which put them at one per decade so far. Two of them happened when waking up in the night so they could have been vasovagal syncopes, and even the third one as a teenager in school could have been due to emotions rather than diseases. After the first and last of them I took all sorts of exams, including to the blood and heart, and nothing suspect was detected.
All of a sudden, as I’m taking the standard test in Autumn 2019, the doctor shakes her head and tells me I’ve plenty of PVCs. She scraps the print and runs the cardiac stress test once again. I still have them. She refers me for a Holter, which reports no less than 10 000 over 27 hours (out of 93 000 heart beats). “Not good” says my family doctor while seeing the result. He refers me to one of the best cardiologists in the area, and here I’m consternated of being suggested betablockers or the ablation. I start reading and worrying, but decide not to do anything rushed. I take the Holter once again after a year – maybe it was just a bad period? – dang, they’re still there. Even slightly more numerous, at 11 000. I start booking the cardiac NMR suggested by the cardiologist to exclude underlying issues, but this is first delayed and than cancelled for the pandemic (I might have a chance to take it now though).
In these days I’ve just repeated the Holter in another country, under the direction of another cardiologist, but results are (almost) the same with 9800 PVCs over 24 hours. This cardiologist is also recommending either betablockers or the ablation, even if it is confirmed the PVCs are suppressed when heart beat goes higher than 130 per minute.
I’ve no symptoms and I’m well overall (well, very stressed, but cannot say whether less or more than the average person nowadays). I’ve tested electrolytes only a few months ago, they are all abundantly within the normal range (including potassium, calcium, magnesium). The cardiologist also made me another echocardiography, and my heart invariably looks completely normal.
Even if I hold medicine (and science in general) in great esteem, I’m very reluctant to undertake a heart surgery when I actually feel well and at 32 of age, and also (but less) hesitant to take medications (I’m not on any so far). I dread these can have heavy side effects, at least according to what I’ve read around and people who take them. This is how I feel, at least, as long as I remain like this: asymptomatic, 10-11k PVCs per day out of 93 000 beats (I know it’s a lot! But I don’t feel any of them, except perhaps for a difficulty in breathing regularly), with a normally-looking heart. Were they to increase, or were I to experience any disturbances, I’d make a reassessment of perspective risks/benefits. I’d also be insanely curious to know how these PVCs could possibly jump from nothing to 10 000 a day, after 29 years of a relatively healthy life.
I wonder (and my only question, if any, would really boil down to this): what are my chances of developing cardiomyopathy or any other serious consequence if I were to make lifestyle adjustments and trying with supplements, but exclude any invasive/dangerous/irreversible step such as the ablation? Let’s assume I remain as I am, especially in terms of the number of PVCs and symptoms (I know these would be big factors).
Thank you for giving us this precious site to learn – and talk – about such a crucial thing as… our hearts.
Best wishes,
Arthur
Arthur,
Obviously I can’t make individual case recommendations but in general for my patients with >10% PVC beats per 24 hours who have no symptoms and whose LV looks normal I recommend watchful waiting. An annual 24 hour monitor and echocardiogram.
This article is a reasonable recent summary
It quotes the most recent 2017 ACC guidelines
he 2017 American Heart Association/American College of Cardiology/Heart Rhythm Society guidelines consider catheter ablation useful for patients who require arrhythmia suppression for symptoms or declining ventricular function suspected to be due to frequent PVCs (generally >15 % of beats and with one predominant morphology) and for whom antiarrhythmic medications are ineffective, not tolerated or refused by the patient.[68]
There are no good randomized controlled trials in this area.
Stay tuned to the blog as I hope to write something in the near future on more advanced therapies for frequent PVCs.
The family history of heart attacks and stents at a young age is a separate issue. I suggest you read this recent post https://theskepticalcardiologist.com/2021/03/06/prevention-of-coronary-heart-disease-the-importance-of-imaging-and-advanced-biomarkers/
and consider getting the testing I recommend to see if you are at risk for early heart attack/stroke.
Hi Dr.
I have a very similar story to your other comments that I have “discovered” during my 10 year affliction with these PVC’s. For the first 5 years, I saw multiple cardiologists and given the same “run-a-round” – “they are benign, just live with them”. To which an answer I found insane as a person heart isn’t supposed to skip a beat like this so often. I’m an IT solution architect and I solve problems, no matter what the problem is.
I started by taking Magnesium supplements because it was all that I could find to say to increase. They didn’t help at all.
I was at work one day and I drank a glass of Orange Juice… They stopped for about 3 hours. Start looking into the contents of Orange Juice… Potassium.
I was a spectator at my son’s high school football games and was eating quite a few sunflower seeds… Slowly after a month of weekly games, I also noticed that my PVC’s were not as common. More investigation showed that Sunflower seeds contain Potassium.
About 4 years ago got my potassium checked and was always told it’s normal (between 3.5 and 5) – but was never told the actual value. Ended up that I was 3.6 – 3.9 each time I had it checked).
I started to increase the potassium in my diet and because I hated these PVC’s so much that I over did it. Increasing potassium too much too fast made the PVC’s worse. I was at 4.9.
This is when I noticed that my symptoms change depending on the potassium level. When my potassium was < 4, I would get PVC’s while my heart rate was less that 90 bpm and only infrequently above 90 bpm. When my potassium was high, I would only get PVC’s while my heart rate was > 90 bpm.
I told my cardiologist about this and he thought I was crazy. (Not a great experience).
Once I stopped increasing the potassium when I was 4.9, it took a few weeks to lower it and low and behold, I was symptom free – for about 8 months. I thought I finally got these things under control and back to a normal life. Was feeling really great and started dieting… and shocker, my potassium dropped below 4 and was experiencing PVC’s again.
Trying to figure out why my body couldn’t maintain a health potassium level, I researched into medications I was taking Verapamil, which is known to affect potassium levels.
Fast forward 2 years of relative PVC’s free time, put on some weight and blood pressure went up. Family Dr. put me on 5mg of Amlodipine to switch off of Verapamil (due to Potassium fluctuations) and then 10mg of Amlodipine to bring my BP back in check. My PVC’s came back with a vengeance. Thinking it was Potassium out of whack again, I started the routine of increasing it in my diet (I was under 4.0). This time no matter what I did, didn’t get any relief from them.
This is when, 2 weeks ago, I saw your (this) post about Amlodipine + potassium levels affect PVCs. I talked with my Dr. about going off of Amlodipine (as a test – remember, I’m a solution architect – I must solve the problem) and he agreed. He also mentioned that it may take up to 2 weeks to eliminate the drug from your system.
The first day after coming off the drug, I had 3 hours of no PVC’s. First time in 6 months I went longer than 5 minutes without one.
I’m happy to report that every day since then (today is day 11 without Amlodipine), is better than the previous day for less and less PVC’s. They are not completely gone yet, but they are now predictable back to the time prior to being on Amlodipine and can be predicted based on Potassium again.
For those of us who have these PVC’s, they are horrible little buggers. I feel each, and every, one since they started 10 years ago. If you haven’t already, I suggest a few things.
#1. Keep a diary of symptoms. Record if you feel them when sitting down, or moving around, or exercising. You might find there is some correlation to your activity and PVC’s. (I did) If you find a correlation, ensure your Dr. listens to you. My Dr. thought I was crazy and dismissed it. I forced him to listen.
#2. Get your potassium checked often (I have a standing order so I can get it checked when I feel I need to). Increase your potassium in your diet first, and then get your potassium checked again in 2 weeks. (Mine increases slowly about .1 for each 2 weeks). Be patient when doing this, increasing too much too fast will also knock your PVC’s into another gear)
#3. Keep looking for answers. There is ultimately a reason for why the PVC’s are happening and maybe you haven’t found a Dr who has had patients with the same situation. It is called “Practice” for a reason. (My GP Dr had no idea about Amlodipine affecting PVC’s because he has never had a patient like me before).
#4. Take some comfort that there are people like Dr. Anthony Pearson here who takes the time to help us and that you are not alone..
Thanks for listening to my story and I hope this may help somebody else.
Please, talk to your Dr first before stopping any medications or making lifestyle changes.
Darren,
Thanks so much for this insightful description of your case history with PVCs. It highlights many points that patients need to be aware of with PVCs and an approach to any medical problem that is worthwhile. With your permission I’d like to include it an upcoming piece I’m writing on PVCs
Dr. Anothony
Thanks for your comment and yes by all means use it wherever you see fit. If my history and information can help anybody in anyway, I will take a great deal of comfort in that.
Let me know if you want any further details.
Hello Dr
I have been diagnosed with PVCs for about 3 months now. I have been experiencing PVCs everyday for the past month. My cardiologist prescribed a beta blocker (Metoprolol 25mg). I have been on this medication for three weeks now with little relieve. Some days I feel them worst than others. Both my cardiologist and PCM have said that they believe they are coming on due to stress or anxiety. I feel very skeptical as to believing them, I feel that is their way of brushing me off. I have no other symptoms other than symptomatic PVCs and tightness in my throat when they come on strong. I ride the Peloton almost daily, which I still have PVCs while riding. They have done blood work and cardio echogram which came out normal. My potassium levels was 4.1 and magnesium level normal as well. Do you think I could benefit from taking potassium? My cardiologist does not seem at all interested in helping figure out what is causing them nor given me anything for them. I actually was started on the beta blocker from a ER doctor.
Yani,
I’m not sure additional potassium will help if you are already >4.0 level. Some readers have found magnesium supplementation helpful even when measured magnesium levels are normal.
Dr. P
Hello Doctor! In case this helps, I am a 57yo female, 5.8″ 150 lbs, mildly active. I was recently diagnosed with PVCs and AIVR (not any symptoms, however) after outpatient wrist surgery. Review of a stress test taken 5 years ago also showed PVCs, but nothing was mentioned to me at the time. My blood pressure has always been low, 100-110/58-70. I’ve had stress-echo, MRI, PET all confirming no damage to heart, and function is fine. 24 hr Holter revealed PVCs 23% of the time. Then I started taking Metoprolol 50mg/day and a month later a 24 hr Holter reveals PVCs 38% of the time. My EP has taken me off the meds and we’ll recheck Holter in 2 weeks.
My blood labs show that everything is within normal ranges. My Potasisum is 4.2 mmol/L and Magnesium is 2.0mg/dL. Your blog stated that some folks have fewer PVCs if their potassium is over 4, which mine is. I read your summary of the MAGICA study (though I assume 720 PVCs/hour is drastically more than I am experiencing??) and your 4 factors to helping patients feel better. I drink 2-3 cups half-decaff coffee per day, I have generally good mental health but could pick up the excercise. Here’s the question, finally 😉 Do you think if I added more potassium through diet or supplements, that my PVCs would lessen? Since I have no symptoms, I would only get confirmation when I have another Holter (5 months). If you think the answer could be yes, then how do I know if my potassium level is consistently at a higher level through diet?… or is supplement the answer here.
BTW, I’ve really enjoyed reading your posts. Thank you.
Karen,
thanks for you comments.It sounds like you are having lots of PVCs. The frequency you are describing is way above the norm.
I don’t think further increasing potassium if the levels are >4.0 will have much effects and as you indicated you don’t really know until you have a monitor what the frequency is.
I an 62 YO male, weight proportionate to height. Never smoked, social drinker, i cup of coffee a day in AM. Exercise regularly by running for years. Been on BP meds since I was 25. Bad genes :). Approximately 2 weeks ago I was having intermittent PVC’s. One week ago they started to ramp up in frequency, anywhere from 2 a minute to 8 a minute. I was actually concerned enough to go to the ER. They ran all the tests. Blood was good (magnesium and potassium were good). They haven’t stopped at all. I had actually bought a Kardiamobile 6L a month ago and I put it to good use and sent my cardiologist 4 strips that he confirmed were PVC’s, annoying but harmless. I have an upcoming appointment this week.
I have been on the following BP meds for at least 8 years, all one a day
Metoprolol ER 50mg
Temisartan (Micardis) 20mg
Amlodipine 10mg
My resting HR is in the 50’s, has been for years
BP is in the 120/75 to 130/85 range
My questions are-
Could the meds be causing the PVC’s even after all these years?
Has my body built up intolerance?
Try combinations of meds?
Am I taking too many meds?
Any ideas I can bounce off my Doctor this week?
I’m obviously not going to start or stop any meds on my own, just looking for ideas….
I can’t offer any specific advice. My comments are for general information.
I have seen patients become more symptomatic with PVCs on amlodipine. Metoprolol is a beta blocker which are typically prescribed to reduced PVCs and telmisartan is an ARB which are unassociated with PVCs for the most part.
I aim for potassium levels >4.
In this situation with new onset of symptomatic PVCs as my posts discuss, I recommend a stress echo which will 1) assess for any dysfunction or enlargement of your ventricles which would indicate underlying structural heart disease 2) rule out coronary artery blockages and 3) Assess whether the PVCs resolve with exercise. I 24 hour monitor to assess the frequency of the PVCs is also reasonable.
Thank you! Your website is a great source for “real life” information.
One last question if I may. Is it even conceivable or possible that one could develop PVC’s or PAC’s from BP meds even after having been on the same meds for such a long period of time? Do you ever see this in your practice?
Hallo Dr Anthony
I wread your post with a great deal of interest firslty because I have had PVCs for about 4 weeks now….I, most aware of them during the day from about 11 am onwards…usually less aware of them in the evnings
I dont feel them when Im active. The are never fast ….. normal HR is 70 bpm
I dont get chest pain or shortness of breath but I do feel uncomrfotable —-I feel like coughing all the time
I was so worried I went to a hsopital emergency department and they found a sodium of 124 and potassium of 3.4. The did a 24 hour ECG and told me that 1 % of my daily beats were ectopics and that the 12 lead looked noraml except for a couple of venticular ectopics which ” came from the same spot in the left ventricular outlfow tract”
I am usually quite healthy…..my kindey function isnt great—-about 67 GFR but other than that Im ative
The dr told me it was a good sign that I dont feel any fluttering when I more actice like climbing up stairs
I dont wnat any invasive procedures.
My echo was quick but the heart look noraml
Im 54 and im thinking maybe its something to do with perimenopause which began 5 months ago
Could I aks if you have any thoughts Id appreciate your suggestions – Im not aksing for a medical consultation because I know you are not in a position to give one on the internet but any thoughts wd be welcome
Most likely as your doctor has described these are benign PVCs.
We have noticed PVCs which are related to menopause and with pregnancy. Changes in female hormones influence many things including the tendency of the cardiac electrical tissues to become more excited.
Excellent website and quite informative. My initial apologies for such an extensive question. I’m a 63 y.o. caucasian male in general good health. About 2 years ago, I was experiencing some rather strange autonomic symptoms and was subsequently diagnosed with panic disorder. After a great deal of failed symptomatic treatment, I was finally prescribed clonazepam and it arrested the symptoms completely ever since. At the time, I also experienced intermittent GERD that was quite intense at times. It was after those episodes that the palpitations began and most often present as trigeminy. I requested a cardiology consult and a holter monitor revealed 17,000 PVCs in a 24 hr. period and ruled benign. I underwent 2 stress echos that were characterized as poor imaging studies due to the frequency of the PVCs and a nuclear stress test was ordered, together with an angiogram despite the fact that I was entirely asymptomatic. I canceled both the test and procedure and instead chose an alternate cardiologist who was rocked backward by the attempt to perform the nuclear test and particularly the angiogram.
It was instead suggested that a CAC be performed, as well as the accompanying CT angiogram with 3D specificity because the former cardiologist had actually made an inaccurate note of being symptomatic merely in order to imply medical necessity to obtain insurance approval. The CAC was 249, 50 at LAD and 199 at LCX. The 3D study noted two small areas of mild elliptical calcified plaque and ruled less than 40% obstruction. A 12-lead performed was normal with the exception of the PVCs. I was placed on atorvastatin 20mg and achieved an LDL of 63 in 90 days. It has remained in that range since initiation of therapy 8 months ago. I was prescribed 50mg of Metoprolol Succinate to try and alleviate the PVCs, which has altered their nature ranging from infrequent to zero palpitations at rest and characteristic trigeminy during exertion or exercise and otherwise asymptomatic. K+ has been normal at 4.1 but my magnesium has never been evaluated. All other labs, including thyroid, are normal. I was on extended PPI therapy for GERD, which increased my concern regarding my magnesium.
My blood pressure was diagnosed as paroxysmal hypertension when the panic disorder was symptomatic, with BP spikes reaching briefly to the range of 200/100, treated with labatelol IV and clonidine P.O. Followup with my PCP alternatively began treating it as primary hypertension because I had apparently become keenly worried that the resulting readings would be extremely elevated and that fear most often resulted in such readings in the office setting. Subsequent readings were continuously lower but I was nevertheless placed on primary HTN therapy, Lisinopril, HCTZ, Amlodipine, to which the Metoprolol Succinate has now been added to address the palpitations. You might well guess that when at home, my BP becomes symptomatic in the way of orthostatic hypotension and extreme fatigue. On exertion, it feels as though I have no energy or stamina to complete my chores. The clonazepam itself already produces a mild sedative effect. So you can imagine the sum impact of all these therapeutic agents upon my general well being, which I have characterized as feeling like an extremely tired old man. I can’t seem to get my doctors to understand that my HTN in their office is due to the fear of being high but at home falls to normal, with readings of 120/75 and often into the range of 107/68 or so when I see readings that are within a normal range, due to a calming effect I suppose. The PCP seems to be persistent in trying to lower my readings in the office setting, at one point using five anti-hypertensive agents that nevertheless failed to quell my physiologic reaction to a fear of extremely elevated readings. They kept commenting that “we have to get that blood pressure down” as though I myself had some direct and immediate ability to influence the readings while in their presence. I consume no caffeine, chocolate or other food substances that would impart any stimulant effect and my diet is quite controlled in being able to achieve the desired LDL. I had also suffered extreme dehydration from working in the summer heat that was being made worse by trying to resolve it with plain water. I assumed that one or more of the medications was to blame because I had never had trouble with heat intolerance or dehydration and yet it was quite dramatic on several occasions, finally brought under control with copious G2 gatorade consumed while producing sweat and water loss.
Effects from anxiety, which has been lifelong, appear to remain influential in my opinion, despite treatment with clonazepam. I take 1mg b.i.d and have wanted to maintain a low dose because of the drug’s nature as a benzodiazepine. It does, however, negate the panic events altogether and with it, the extreme BP spikes that I felt would eventually increase my risk for other problems. My cardiologist stated that the PVCs are not the type associated with HTN so that is of considerable comfort but yet they persist and I believe largely due to the anxiety component. I have no interest in an antiarrythmic because of increased mortality risk shown in studies and I’d be really hard-pressed to believe that ablation would be practical in my instance, particularly since I’m asymptomatic. I also doubt that since the PVCs now represent about 25% of the original finding on Holter monitoring that I’m at risk for cardiomyopathy. Yet I can’t imagine an increase to the metoprolol in the presence of already being so lethargic and limited in general and on exertion.
So my HX is somewhat of a predicament in that I can’t seem to get it fine-tuned such that the palpitations can be controlled and yet not suffer from polypharmacy relating to the BP meds. There is apparently a very stubborn and single-minded effort to achieve a target BP to match the LDL reduction but it does not take into account my paroxysmal factors or the side-effects of so many drugs in attempting to do so.
At long last my question to you is what, if anything can I do to try and break the cycle in the approach being taken to one that more realistically accommodates all of my factors rather than a singular goal? Can the combination of all of these anti-hypertensive agents somehow result in the PVC patterns? Or can GERD and gastrointestinal manifestations produce PVC complexes such as mine? I do note a temporal context in that regard but I’m careful to avoid cause-and-effect thinking practices. Is it more likely the presence of anxiety, despite treatment with the clonazepam? Could these palpitations be subsequent to and persistent from low magnesium? I simply know that I can’t continue forward in a manner that has reduced my quality of life to a point that makes me continually feel like a man in his 90s rather than his 60s for a person of reasonably good health. Having palpitations yourself, what would you suggest the best course of action to be to achieve the most balanced approach to longevity through treatment of my health issues and yet lower the negative impact to my well being?
Thanks a great deal for your time and any attention to my difficulty.
Yours is a complicated case for sure. You definitely need a physician who is willing to listen to you about side effects and tweak medications to reach an ideal balance between BP goals and your quality of life.
One thing I would tell you is that I have found amlodipine to be a trigger for PVCs in many patients. It is a direct arterial vasodilator and can cause reflex autonomic responses.
Could you elaborate on Dr. Sinatra being a semi finalist for quack?
I could but there is a very good chance lawyers would descend upon me.
Fair enough, understood
Hi Doc,
I’ve discovered your blog when researching PVC’s and I’ve learned so much already!
A quick note on the watches breathe app that you might not know, the breathe session is used as a measuring time for HRV by the apple watch. Every time you do the 1 minute guided breathing, a new value for HRV will be posted under your phone’s health app. It doesn’t seem to work when you move too much during the breathing.
Hello,
I was curious to ask if acupuncture therapy in conjunction with herbal remedies have any merit in reducing PCV’s? I read some articles that seem to indicate that it does help, but also say links on this website that says acupuncture does not work and is nothing more than a placebo.
https://www.healthcmi.com/Acupuncture-Continuing-Education-News/1798-acupuncture-regulates-cardiac-arrhythmias
https://www.ncbi.nlm.nih.gov/pubmed/21362312
I’m unaware of any legitimate scientific studies showing benefit for patients with symptomatic PVCs. The first study you list is bizarre and the website is an acupuncture education site. The article doesn’t list any references that are available to review in English.
The second study is about a specific combination of 12 different herbs called SSYx.
“Sheng Song Yang Xin (SSYX) is based on a traditional Chinese medicine prescription that combines 12 different herbs and has been in use for centuries as a treatment for cardiac ailments (supplementary Table 1) [7]. More recently, the same formulation has been standardized, encapsulated, and approved in 2003 as an antiarrhythmic agent by the State Food and Drug Administration of China (Z20030058). SSYX is used commonly in China on its own or in conjunction with conventional antiarrhythmic agents. In a multicentre randomized clinical study, SSYX reduced PVCs burden in patients with symptomatic, frequent PVCs by 74.2% and 65.8% in patients with and without structural heart disease [8]. In a separate, double-blind, randomized, placebo-controlled trial of patients with symptomatic bradycardia that did not meet conventional criteria for permanent pacing, SSYX increased MHR by 13.3% without any serious adverse events reported ”
I would be very wary of taking SSYX. They have no idea what the active ingredient is or how it works. One huge lesson that cardiology learned from the CAST trial was that supprressing PVCS is not neccessarily a good thing.
Interesting article. I have been struggling with distracting PVCs for several months now, and was 100% certain that they were due to taking and/or changing / withdrawing from antidepressants. I have always had occasional palpitations, but when I switched depression meds last year, they came on like a switch was flipped, and have not stopped. I had a bunch of tests done by my cardiologist (ECG, ECHO, 48-hour monitor, stress test), and he says they are benign and does not agree that they have anything to do with the depression meds. Having been off of all antidepressants for over 6 months now with no change in PVCs, I am starting to wonder if it could be the HCTZ or dessicated thyroid that I have been taking for many years.
HCTZ and electrolytes: I am always conscious of the amount of potassium in my diet, and occasionally take Mg supplements, but maybe I am not hitting the mark for either one. Going to see how much I am actually taking in every day and maybe invest in some V8.
You mention monitoring thyroid levels: I have suspected that my thyroid meds are inadequate for quite a while now, but the tests always come out ok. So then I blame my problems on depression. What should I be looking for in a thyroid test? I get tests for TSH, T4, T3 and Free T4 .
Do you think I should try switching to synthetic thyroid? Switching my diuretic? I have a script for metoprolol that my cardiologist reluctantly gave to me. I have only taken it twice to get temporary relief from the palpitations, but I am scared to become reliant on it. Maybe I should try it regularly to cover both my HBP and palpitations? So many variables! Would appreciate any advice regarding a plan of attack. Willing to experiment.
Re: antidepressants and PVCs. I’m not aware of antidepressants as a common cause of PVCs but in any individual they could be playing a role. Depression and anxiety often go hand in hand and anxiety leads to activation of the sympathetic nervous system which in turn can make PVCS more frequent or more symptomatic.
HCTZ can be a trigger as it lowers potassium and as I’ve written I recommend trying to keep potassium levels above 4. Also, there are studies showing magnesium depletion in patients taking HCTZ and magnesium supplements prove helpful for many patients with PVCS.
For thyroid testing I utilize TSH level with a reflex to free T 4.
For patients with hypertension and PVCs, beta blockers can be very helpful.
Thank you for the wonderful comments. Its great to know we are not alone in this and we have a Dr. Who makes us feel at ease. Ive had lots of stress lately which brought on plenty of anxiety. This in turn has plagued me with hart palps for the last almost 4 months. Ive wore a 48 hour monitor and had a. EKG and everything is benin. After reading that mag and potassium defitioncies can cause PVC ‘s, I am taking Magnesium Glycinate and take an Adrenal Coctail. 90 % of the skipped bets have disapeared. I am so grateful, its. Like getting my life back. I do still have some throughout the day but .ill take it, because I have tried everything elseto getrid of the.Thank uou for uour time on here. Please let us know when you have new information to share.
I am very sorry, but perhaps they are not “quacks” for saying Magnesium helps? I suffer serious PVC’s, I have been to cardiologists that are rated as the highest in their field in America and in Germany, 4 times they told me, make sure my Magnesium intake is supplemented. Also, even just today I had an attack of PVC’s, I even thought I might pass out. I took 300mg of Magnesium orally, a powder substance brand that dissolves in mouth, and within 30 minutes, I felt like going for a jog. So, not saying your not also excellent, but maybe, you should rethink Magnesium and not be so closed minded? Magnesium has been my go to for bad PVC days for 2 years and always works.
Dr. AnthonyP, a recommendation for your magnesium research and documentation, please review the book “The Magnesium Factor” by Dr Mildred Seelig, MD. Look forward to seeing your thoughts.
I am 62 and started having PVCs in my 20’s, at which time I saw a cardiologist and assured they were benign. I’ve had them all my life and while I had a stent 2 years ago, it was unrelated to that. So 2 weeks ago I saw an article about taurine and how it can help with PVCs as well as other cardiac rhythm issues. I started taking 1000 mg in the AM and another at night. The PVCs have almost completely stopped. Any thoughts on taurine?
I would put taurine in the category of nutritional supplements with no scientific support for efficacy for anything. However, if it almost completely stopped your PVCS that is fantastic for you. Keep me updated on whether it is a durable cure as PVCS come and go randomly often and there may be other factors playing a role.
I’m a big supporter of self-experimentation (as along as it is safe) and if an individual finds a particular supplement that cures them of their PVCS without any side efffects (no matter the mechanism) they should go with it but don’t assume it will work for anybody else.
I am on Metoprolol for blood pressure and Tachycardia which has helped. Do you think it also can help with PVC’S? I take 100mcg’s daily.
beta-blockers like metoprolol are often utilized to reduce the frequency of PVCS and/or the symptoms patients experience from their PVCS
Hi Dr. I have had AVNRT and received a cardiac ablation in October 2017. After the surgery, I became very aware of my heart and PVCs. I wore a monitor after the procedure and found out that my PVCs represented a very small percentage of my heartbeats (<3%). However, I do notice an increase in PVCs when I exercise. I believe this is because my heart is more excited during exercise or because I used to get my episodes of AVNRT when I exercised. Either way, I’m always concerned that PVCs will lead to SVT during exercise (I’ve had 3 episodes of AVNRT since my ablation). EKGs and echos have all been normal. Any advice?
Most benign PVCs (assuming you have a structurally normal heart and yours are benign) improve with exercise. I have never seen AVNRT triggered by stress induced PVCS.
Well written and informative. I suffer from occasional bouts of PVCs. Thanks for all the tips.
Great article. Thank you.
Hi! I’m wondering about your view on hormonal changes and PVCs? My cardiologist said they could be related, without any real explanation. I notice my PVCs much more strongly during and immediately after my period (my intense PVC episodes started 5 years ago at age 35, though I’ve noticed the occasional PVC as long as I can remember). I will then often have 2 to 3 weeks per month that I notice none. Thanks!
Hi! I’m glad I came across your comment, as I think I am in a very similar situation… The frequency of pvcs changes for me as I go through my cycle.. So far I’ve noticed them getting progressively more frequent right after my period ends, and they disappear several days before my period begins, and for its duration. Weird.. Do you have any new information at all on the subject?
There is a 2016 study which found
VPB frequency decreases with estradiol peak in the ovulation period. This suggests that estrogen may have protective effects against ventricular arrhythmias.
https://pubmed.ncbi.nlm.nih.gov/26842421/
Thank you Dr Anthony, I am using capsules of magnesium chelate, made in Australia with brand name, Nature’s Own, 500 mg,eq to elemental magnesium 100mg. The recommended dose on the bottle for cardio health is one capsule twice daily with food. I must add that I Also take a beta blocker, metoprolol, which I have been on for years, but lately, it had become ineffective in preventing palpitations by itself. I am still taking it along with a blood thinner, warfarin. The addition of magnesium has eradicated the arrythmias altogether, at least for the last 5 weeks and I am hoping I can cut back a bit on the beta blocker. May I also add that my blood pressure is now perfect, according to my GP, and my temperament, according to my wife, is very much improved. My energy levels are a lot better and exercising is much more pleasant, as you would expect. I have always been sceptical of alternative medications and too cautious to try anything other that what a qualified medical doctor would prescribe. That is why I believe it is best to get the OK from your doctor before taking any form of medication.
Good to hear magnesium worked so well for you. Magnesium chelate means magnesium plus an organic compound, often citrate. We use mag citrate for constipation and for cleaning out the gut prior to colonoscopy and i can testify that it works really well in that regard.
I have been suffering from benign pvc’s for at least 40 years and have tried nearly every medication that can be prescribed. I am 81 and healthy. I have had an av block and pacemaker fitted( on second one), yet I still get pvc’s or did until 5 weeks ago. This is when I started to take magnesium chelate supplements. I had been following Dr. Sanjay Gupta, a cardiologist from York, in the UK. and reading widely on the internet. Magnesium kept coming up, so I asked my GP if I could try it. He said yes but be careful to consult a pharmacist about the best sort for my condition. The result is, I have not felt any pvc’s. since. I do avoid chocolate, caffeine and any known triggers. My energy levels have increased, my breathing is better and I feel years younger. Magnesium has changed my life. Try it for a few days, like I did.
Denis,
Glad that worked for you. Can you provide details on the dosage and form you are taking?
I have been working on a post specifically about the best way to take magnesium supplements.
I found this article today after googling magnesium and PVCs. I’ve had benign ectopic beats for the last 5 years, and they cause me a lot of stress sometimes. I just try to ignore them, but the last two days, they’ve been worse than ever before.
And then I took liquid magnesium citrate last night for a different problem entirely, and the palpitations just…stopped. Like went from worst ever to nothing within an hour. They’re still gone today, almost 20 hours later. I’ve never heard anything about magnesium helping palpitations until now, but it was such a dramatic effect that I, of course, had to google it. I’ve already been on the phone with my cardiologist’s nurse to ask if it’s okay to take a magnesium supplement every day. I hope they don’t think I’ve been listening to quacks or anything…it was truly an accidental (and happy) discovery, and I just really, really hope that the effects are consistently reproducible for me.
Ashley,
I’m trusting this is a real experience in which case I say, hooray! I’ve been researching a separate article on magnesium supplements, hoping to clarify which are most effective with least side effects. Mag citrate, of course, is traditionally used in bowel preps prior to colonoscopy to clear things out. Did you get any GI side effects?
Thank you for this informative article, especially the part about foods rich in potassium. I did find it helpful to eat a tomato every day! Is there a connection between benign PVCs and inherited peripheral nerve disease (charcot-marie)? . I have both. Thanks again.
Most forms of Magnesium supplements are barely absorbed by the body. Magnesium oxide is practically worthless, and is also the most commonly form prescribed and used.
Re-Mag kills my PVC’s without loose stools, but nothing else does (cheated from work…but only at levels that cause diarrhea).
Docsiders,
I hope to present my magnum opus on magnesium supplements in the near future. It is a very complicated topic and I think this explains why there are so many choices on the market and so much nonsense written on the topic. I’m going to assume you are not somehow benefiting from the sale of ReMag and that it truly works better for you than magnesium oxide (the supplement physicians almost universally prescribe)
I have no idea if I am having PVCs or not. I’m currently out of the country traveling and these just started 2 week ago. I am a non-smoker, moderate drinker, walk 1 hour per day, don’t drink caffeine or sugar drinks. I was diagnosed with a hole in my heart 3 years ago but no treatment was required. I am on 25mg of Losartan for high blood pressure but it’s been under control for years now and I am being tested again to see if it’s needed. I had all the heart tests 3 years ago with all coming back fine. I did have a severe 2 month diarrhea cycle recently which is now making me feel like this caused me to have low potassium? Could this have triggered PVCs? What to do till I get home? (In Mexico). PS no pain, no dizziness…normal symptoms. THANK YOU!!
This is great information and thank you for taking the time to write it. I am in the medical field myself and have been suffering from PVCs since a kid. They are very symptomatic. I had many tests done including a heart scan (that was useless and a stupid thing to do), a 24-hr holter and echo. The last echo came back normal. The holter results were:
Sinus rhythm, 37 – 102 bpm, average 57 bpm. Nocturnal bradycardia suggests high vagal tone and is normal.
Rare premature ventricular contractions (14 beats, 0%)
Rare premature atrial contractions (76 beats, 0.1%)
Patient reported 15 episodes of “heart palpitations”. Out of 15 episodes, most (6/15) were sinus rhythm. 5 episodes recorded one PVC.
No sustained arrhythmias seen. No significant pauses (longest R-R interval 1.8 seconds at 1:45 am).
As you can see, when I strongly feel something, many times it doesn’t even register as more than sinus rhythm. So the cardiologist thinks I’m crazy and shoos me away. But I can feel my pulse and I am definitely skipping a beat and usually about 15-30 times a day. It is very unpleasant.
So here is my question: Since my cardiologist doesn’t even want to consider potassium, medication or anything, I want to try to self-supplement. I bought 99mg hard tablets of K-Gluconate. There are warning signs everywhere I could die. I know you can’t give medical advice here, but what do you think is a safe dose to start with? 1 pill/day, 2? 3? I just want to see if it has any effect at all. And while I know you aren’t a big proponent of Mg, I also bought some Magnesium Oxide pills to go along with it.
FYI: I do cardio exercise 3x/week, I don’t drink alcohol or caffeine and I eat a very healthy balanced diet. I also sleep 7-8 hours a night. Lifestyle is not a big factor for my problem, I think.
Thank you again for all the wonderful information here! It is appreciated.
Mike,
Thanks for your kind comments.
Your question about potassium supplements is a really good one and prompted me to dig around a bit to give an informed answer.
Lots of my patients are on potassium supplement pills because they are on diuretics like furosemide (Lasix) which causes potassium depletion. For these patients we typically dose with prescription strength KCL at increments of 10 meq. 10 meq KCL=750 mg and these are large pills. We carefully monitor potassium levels in the blood in any patient receiving potassium pills.
Potassium gluconate by weight is mostly gluconate. When you say 99 mg you are referring to the mg of potassium, usually in a 595 mg K gluconate. this would provide 99/39 (molecular weight of potassium) or roughtly 2.5 meq.
It would take 4 of these daily to equal the typical supplement dosage that I prescribe.
The warnings about potassium are because if you have kidney failure, potassium levels can rise to dangerous levels.
Consequently I would not advise supplementing with potassium unless you have had blood testing showing
normal renal function.
Another thing to keep in mind is that there are reports of potassium supplements damaging the lining of the esophagus so it is important to take potassium pills with a large amount of water and it would be better to divide up the doses.
I’ll publish a post on potassium supplements as time permits. Another way to supplement potassium is with “salt substitutes” like Nu-salt or Morton’s salt substitute. A brief look into this , however, tells me that it is a very complicated field.
The best way to raise potassium levels is by eating foods with good potassium levels which I believe I listed in the post.
So nice to know I am not alone there with my PVCS 🙂
I’m wondering if you have any insight into this. I’ll try to be brief with my background.
I’ve had PVCs for many, many years. I was diagnosed with them by admitting myself into the ER when I was getting a particularly bad string of them about 15 years ago. The doctor hooked me up to a 12-lead EKG and diagnosed me with them, mentioned they were benign, and sent me on my way (NOTE: I do believe I’m going to get an echo soon as they’re still present and I’m not sure a person can really determine they’re benign by just an EKG, no?).
In the last three years, I’ve had two kids, moved, and have had a stressful number of situations at work and am finding myself dealing with these dreaded things again, and more frequently. To top it off, I strongly believe I feel each and every one of them. I know many people don’t feel them, but I believe I’m plagued in that I feel it whenever it happens. I’ve almost become hypersensitive to the sensation and sometimes I feel a stress-induced jolt of adrenaline when one happens.
Now onto my question: they never seem to happen with exercise, and I can get my heart out of bigeminy (when it does go into bigeminy), by simply moving about. They appear to ease with exercise and return at rest. But the “spells” for me (which can last a day or two and can have a month or so in between) consistently start during early morning hours. It started when I would awake at random times in the night to hand my 1-year-old a bottle. I’d lay back down and “thump”, I’d start feeling them. Now I can just wake up to use the restroom, or just to turn around, and there’s a good chance I’ll feel the dreaded “thump”. If I felt one at night, then during the next day the prevalence of them is a lot higher, as well as the chance of bigeminy.
My question is: why the early morning hours? What’s happening here? Is it something with the parasympathetic tone? Sometimes I’ll even dream that I’m having them and then wake up to them. Any thoughts as to what might be going on?
Thank you for your posts. They are, as others have said, comforting. Wondering your opinion on retesting. I’ve had PVCs since I was 15 (63 now) and they have come and gone over the years, attributed to hormones, low potassium, stress, and dehydration/bad diet. Recently they started again and are driving me insane and none of the usual fixes are working. Two ER visits with normal EKGs and my cardiologist all say no worries. I’m thinking maybe I should have another ultrasound, buy MD doesn’t think it’s necessary. I had a perfectly normal cath in 2015 but no tests since. Your thoughts? Thank you.
Good question. I consider retesting for patients who have not had documentation of “structurally normal heart” for some time and who have a significant change in their symptoms. You would qualify since no testing in 3 years and worsened symptoms.
Typically I would order a stress echocardiogram which allows a reassessment of both LV structure and function and for any blockage in the coronary arteries and I would consider some kind of monitor-a 24 hour Holter would be fine if you are having daily symptoms.
You might also consider acquiring an AliveCor device to monitor your rhythm with symptoms. I’ve written a lot about this elsewhere on this site. Unfortunately AliveCor does not identify PVCs but if you connect via KardiaPro with your physician your recordings can be viewed and interpreted by him/her.
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
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.
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?
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.
Very calming and reassuring. Thsnks
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.?
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.
Thank you… I will follow up with my cardiologist.
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…
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.
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?
Thanks.
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.
What magnisum? I have svt/afib well there still trying to figure out ughhhh!! Dr wants me to try diltizam or ablation.
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
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
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.
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?
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?
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.
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.
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
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?
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.!
Thank you so much for keeping us (thoroughly) informed
Very nice information. Thank you! ?