One of the many things I enjoy about writing this blog is the interesting comments and questions that readers post. Many of them stimulate me to better answer and inform my patients.
Here’s one such question (about premature ventricular contractions):
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.
This was the response I typed off the top of my head:
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.
The answer reflects my clinical practice, which is based on 30 years of experience taking care of patients with PVCs, in conjunction with regularly reading papers, reviews and guidelines in this area.
Periodically, both for specific patient problems and for blog questions, I will search the medical/scientific literature and review guideline publications to see if there is any new information that I am unaware of to ensure that my recommendations are scientifically grounded.
In this case, a more prolonged search of the literature did not yield precise guidance on the frequency of retesting of patients with benign PVCs.
This 2014 guideline comments briefly on the evaluation and treatment of PVCs without structural heart disease (SHD):
In the absence of SHD, the most common indication for treating PVCs remains the presence of symptoms that are not improved by explanation of their benign nature and reassurance from the physician.
In addition, some patients may require treatment for frequent asymptomatic PVCs if longitudinal imaging surveillance reveals an interval decline in LV systolic function or an increase in chamber volume.
For patients with >10,000 PVCs/24 h, follow-up with repeat echocardiography and Holter monitoring should be considered.
In patients with fewer PVCs, further investigation is only necessary should symptoms increase.
It should also be recognized that PVC burden often fluctuates over time.
This initial testing approach corresponds closely to what I wrote in my post on benign PVCs here.
Retesting with echocardiography and Holter monitoring is advised for those few patients who have lots of PVCs, but the frequency of this retesting is not specified and cardiologists have to use their best judgement, balancing the cost (to patient and to society) and patient safety. Most cardiologists will err on the side of more frequent repeat testing for a variety of reasons.
Personally, I will advise an annual echocardiogram to such patients since they are at a higher risk of developing a cardiomyopathy.
In the absence of really frequent PVCs (>10,000 per 24 hours is a nice round number, but the precise cut-off is debatable), we should probably only repeat testing if the patient recognizes a significant change in their symptoms.
The reader clearly fits into that category, and retesting in her will provide reassurance that all is still good with her heart. This, in turn, should help with managing symptoms and preventing recurrent ER visits.
The final question (and the toughest) that we could pose related to retesting is “What is the time interval that one should wait before retesting in a patient with worsened symptoms?”
For example, if the reader had a normal echocardiogram 6 months ago should we repeat it when symptoms worsen? My reflex answer would be no, but at some time interval depending on the individual characteristics of the case-patient risks for heart disease, patient anxiety levels, patient symptom severity and frequency, the answer would become yes.
Cardiologists have to answer dozens of questions like this daily. There is no science to inform a precise answer, consequently the answers will vary wildly from one cardiologist to another depending on a variety of factors specific to the cardiologist.
Those cardiologist-specific factors are complex and sometimes controversial. Part of this makes up the art of medicine and part reflects the business of medicine. They are definitely worthy of another post when time permits.
Questioningly Yours,
-ACP
N.B. The Eternal Fiancee’ (my layperson surrogate) expressed surprise that one could have 10 000 PVCs per day. I told her that if your heart beats roughly once per second (6o beats per minute) since there are 60 x 60 x 24 = 86400 seconds in a day, your heart beats almost 90 000 times in 24 hours.
Thus, roughly 1 in 9 beats is a PVC.
4 thoughts on “The Skeptical Cardiologist Answers Good Questions: Retesting For Symptomatic Benign PVCs?”
I was just diagnosed as having frequent PVCs (I’m 34). Holter monitor tells me I had 85,000 PVCs in 48 hours (ventricular arrhythmias percentage was 39.1). This included several days of no caffeine leading up to the monitor, no caffeine on day 1 of the holter, and resumed caffeine on day 2. Is this percentage so high that it would not be wise to NOT start beta blockers? Is there a certain threshold that medication or catheter ablation is truly a better path than trying to eliminate stress or making other lifestyle changes?
Ariane,
Good questions. In my practice I would only consider drug or ablation treatment for PVCs with symptoms or if there was evidence for the frequent PVCs causing problems with the function of the left ventricle. When the frequency is >10% of beats the possibility of cardiomyopathy increases so I would perform surveillance echocardiography too keep an eye on LV function. In the case of very frequent PVcs we don’t have solid information on long term outcomes with and without treatment so best to be under the care of a cardiologist who fully understands the situation but has no bias towards invasive treatment.
I’d agree, broadly, with your approach and adopt similar. My ‘threshold for concern’ is perhaps a little higher – I use 15% of cycles in 24hrs… I’ll have to track down a reference for that. Retesting interval is tough, I agree. I think individual context is important as well. I have a similar patient who is a marathon runner for example… but again I suspect that this is intuitive rather than evidence based.
I really enjoy reading your blog especially since I moved into the role of cardiac nurse navigator last month. I help patients after discharge by going over their meds, diet, wound care, helping make f/u appointments, etc.
I am blown away by the sheer number of CHF patients. I now have made some personal lifestyle modifications of my own: taking the stairs and no added salt to my diet. I have many more improvements to go but I tell myself, “baby steps”.
Always appreciate what you have to share here. Thank you. ❤