Transcript PVCs - Sydnee Burgess

PVCs
Sydnee Burgess
Riverside FHT, PIFM EBM
April 27th 2016
objectives
• What are they?
• How do they present?
• Are they dangerous?
• How do you investigate them?
• When and how do you treat them?
Case
• Mrs T, 72y.o. F, here for her PHE,
• PMHx T2DM
• On P/E: irregular heart rhythm
• Do an ECG: PVCs
…WHAT NOW?
• Many names…
• Ventricular premature beats/complexes
• premature ventricular complexes/beats/depolarizations
• ventricular extrasystoles
What are they?
• Triggered activity resulting in afterdepolarizations
• Mechanism:
• re-entry (most common /RVOT. Sometmes LVOT or hemifascilar/Purkinje),
• enhanced automaticity
• abnormal automaticity
• If 2-hour ambulatory monitoring used, up to 80% of healthy people
have PVCs
• Age-related prevalence
• ↑ frequency associated to:
• Bad cardiac stuff: HTN w LVH, acute myocardial infarction, heart failure,
myocarditis, hypertrophic cardiomyopathy, congenital heart disease,
idiopathic ventricular tachycardia
• Chronic lung stuff: COPD, sleep apnea, pulmonary HTN, other pulmonary
diseases,
• Endocrine stuff: thyroid, adrenal, gonadal
• Sleep disruption (in hospital settings)
• Drugs/Substances: Nicotine, alcohol, sympathomimetics (beta-agonists,
decongestants, antihistamines). cocaine, amphetamines NO evidence for
caffeine utilisation
• Estrogen may have protective effect
How do they feel to patients
• vast majority: few or no symptoms
• Palpitations (primarily) secondary to the hypercontractility or postPVC beat or feeling that the heart has stopped secondary to a postPVC pause
• Sometimes: pounding sensation in the neck, lightheadedness, near syncope
• difficulty breathing, chest pain, fatigue, and dizziness(9))
• Rarely, hemodynamically compromise: in patient with
• severly depressed LV function or
• underlying bradycardia, can hemodynamically compromise
P/E
• Irregular pulse
• S2 splitting depending upon R or L Bundle branch morphology
• Grade 0: no VPBs
• Grade 1: unifocal and infrequent VPBs <30/h
• Gradde 2: ≥30/h
• Grade 3: multifocal
• Grade 4a: 2 consecutive (couplets)
• Grade 4b: 3 or more consecutive (aka non-sustained Vtach)
• Grade 5: “R on T phenomenon”
… do PVCs predispose to Vtach?
Are they dangerous?
• Site/ origin/ pattern (multifocal PVCs, R on T phenomenon,
bigeminy/trigeminyg/quadrigemny) have no prognosic
importance…(Uptodate)
• Presence of simple PVCs in patients with apparently normal hearts is
associated with increased mortality
• Meta-analysis (n=3629) Two fold incease in SCD, IHD (1/8 excluded underlying
structure disease)
• Meta-analysis (n=106 195 gen pop) frequent VPCs (15-20% of heartbeats) ↑
x2.07 cardiac death (no exclusion of underlying structure disease)
• R-on-T phenomon and NSVTach
• 2005 study 178 retrospective cohort study (n=178)
• Follow up after 5.5 ± 3.4 years: 1.1% annual mortality rate (n=11, 6%. 5 with NSVT)
• Correlate 24hr ECG to clinical outcome
• NSVT positive predictive value of sudden death of 9%, Negative predictive value of 95%
• Important in subset at risk for polymorphic ventricular tachycardia or Vfib =
ACS, Brugada Syndrome, malignant of early repolarization and idiopathic
ventricular fibrillation
• 2) pvc associated cardiomyopathy in 07/2015 study:
• “Frequent PVCs, defined as greater than 20% of all QRS complexes on
standard 24-hour Holter monitoring, are associated with the presence or
subsequent development of left ventricular dilatation and dysfunction.
Catheter ablation of frequent PVCs has been demonstrated to be effective at
PVC suppression and is associated with improvement or normalization of
ventricular function; thus defining a specific, reversible form of ventricular
dysfunction termed PVC cardiomyopathy.”
• NSVT assoiacted to LVH (p=0.01) and severe symptoms NYHA III-IV (p=0.04)…
• “In patients presenting with high burden PVCs, an assessment for
symptoms and associated cardiomyopathy is warranted and, in the
appropriate clinical setting, PVC catheter ablation may be a
reasonable treatment option.”
Approach
• 1) Find a PVC if Symptoms/Signs/physical exam  search for PVC:
ECG  24-48hr Holter (also best for %) 30 day loop monitor
Approach
• Journal to correlate triggers
• BW: E+, TSH
• For nocturnal: polysomnography to r/o sleep apnea
Based on 07/2015 Study: high frequency PVC (>20% of heartbeats)
warrants further investigation
to r/o underyling structure (prognostic value)
Approach
• Echocardiography
• cardiac structure and function
• Exercise treadmill stress
•
•
•
•
response of the VPBs to exercise,
PVC morphology 
if sustained or nonsustained V Tach induced with exercise
screen for underlying ischemia
Workup in the general population
• No guidelines??
• Uptodate says: everyone (written by cardiologists)
• Medscape says:
Treatment
• Treatment goals include palliating symptoms, restoring cardiac
function if affected, and preventing progression to tachycardia-related
cardiomyopathy if the PVC burden is high, even in patients without
symptoms. (9))
Treatment
• If presence of symptoms
1) Abstain from known triggers
2) BB, less commonly, a CCB (Grade2C)
3) Antiarrhythmic medications or
1) Antiarrhthmic: Flecainide Propafenone calss Ic highly effective. CI: CAD
(proarrythmia and increased mortality)
1)
If Ic CI: Amriodarone and Sotalol
4) radiofrequency catheter ablation (depending on patient preference)
1) If LV dysfunction and frequent PVCs
Treatment
• If presence of symptoms… does not improve mortality
1) Abstain from known triggers
2) BB, less commonly, a CCB (Grade2C)
3) Antiarrhythmic medications or
1) Antiarrhthmic: Flecainide Propafenone calss Ic highly effective. CI: CAD
(proarrythmia and increased mortality)
1)
If Ic CI: Amriodarone and Sotalol
4) radiofrequency catheter ablation (depending on patient
preference)
1) If LV dysfunction and frequent PVCs
Treatment
• If presence of symptoms… does not improve mortality
1) Abstain from known triggers
2) BB, less commonly, a CCB (Grade2C)
3) Antiarrhythmic medications or
1) Antiarrhthmic: Flecainide Propafenone calss Ic highly effective. CI: CAD
(proarrythmia and increased mortality)
1)
If Ic CI: Amriodarone and Sotalol
4) radiofrequency catheter ablation (depending on patient
preference)
1) If LV dysfunction and frequent PVCs
Radiofrequency catheter ablation: when?
• American College of Cardiology/American Heart Association/European Society of
Cardiology: ablation of PVCs useful in:
- PVCs frequent, symptomatic, monomorphic, refractory to medical therapy or
patient chooses to avoid long-term medical therapy
- Ventircular arrhythmia storm that is consistenly provoked by PVCs of a similar
morphology
European Society of Cardiology:
- For patients with LV dysfunction and frequenty symptomatic PVCs or
nonsustained Vtach
- Decline in ventricular function due to RVOT-PVC burden
- Idiopathic V Fibrillation leading to implantable cardioverter defibrillator if
experienced operators.
PVC in the athlete
• eligibility for sport PVBs may =sign of an underlying dangerous heart
disease of which the athletes themselves may be unaware
• 1)exclude underlying heart disease:
• echocardiogram,
• maximal stress testing,
• 24-h ambulatory ECG
• 2) if PVC associated to excerciseDeconditioning (3–6 months) is
recommended (and if resolution is demonstrated, all sports are
allowed) in symptomatic athletes, with >2000 PVBs/24 h,
polymorphic PVBs or couplets, or increased by exercise.
PVC in the athlete
• European Cardiology Associations: if –ve workup +
•
•
•
•
Ø FHx SCD or arrhythmogenic diseases
Ø PMHx of heart disease /↓ LV fn
Ø prolonged palpitations, pre-syncope/syncope every early
Ø repetitive PVBs +short RR interval that are polymorphic and prevalent during exercise;
• American Heart Association and American College of Cardiology suggest that athletes without
structural heart disease who have PVBs can participate
• øPVBs increase in frequency during exercise or exercise testing and convert to repetitive forms,
• If so, further investigation to rule out underlying disease. If structural disease defined  acitivty limited to
low-intensity class IA competitive sports
• If sx of pre-syncope, fatigue, dyspnea, the athlete should be limited to cintensity of sports below that
threshold (Zipes et al., 2015).
• Study Group on Sports Cardiology of the European Society of Cardiology:
•
•
•
•
Ø FHx SCD
PMHx structural or arrythmogenic heart disease (Tx or not)
<2000 PVBs/24 h
not polymorphic PVBs or couplets
objectives
• What are they?
• How do they present?
• Are they dangerous?
• How do you investigate them?
• When and how do you treat them?
Thank you
• Catheter ablation…. Not as invasive as thought:
• https://www.youtube.com/watch?v=ybP-5Ji1G2s
• 1)Podrid PJ, Lampert S, Grboys TB, Bltt CM, Lown B. Aggravation of arrhythmia by anti-arrhythmic drugs – incidence and
prevalence. Am J Cardiol. 1987;59 (11):38E
• 2) Lauribe P, Shah D, Jais P, Tkahashi A, Haissaguerre M, Clementy J. Radiofrequency cather ablation of drug refractory
symptomatic ventricular ectopy: short and long-term results. Pacing Clin Electrophysiol. 1999; 22 (5):783
• 4) LeeV, Hemingway H, Harb R, Crake T, Lambiase P. The prognostic significance of premature ventricular complexes in adults
without clinically apparent heart disease: a meta-analysis and systematic review. Heart. 2012 Sep; 98 (17):1290-8. Epub 2012 Jul
10
• 5) D’Ascenzi F, Zorzi , Alvio F, Bonifazi M, Corrado D, Mondillo S. The prevalence and clinical significance of premature ventricular
beats in the athlete. Scand J Med Sci Sports 2016: doi: 10.1111/sms.12679
• 6) Circ Arrhythm Electrophysiol. 2014 Apr;7(2):237-43. doi: 10.1161/CIRCEP.113.000805. Epub 2014 Feb 12.Radiofrequency
ablation versus antiarrhythmic medication for treatment of ventricular premature beats from the right ventricular outflow tract:
prospective randomized study. Ling Z1, Liu Z, Su L, Zipunnikov V, Wu J, Du H, Woo K, Chen S, Zhong B, Lan X, Fan J, Xu Y, Chen W, Yin
Y, Nazarian S, Zrenner B. Pacing Clin Electrophysiol. 2014 Jan;37(1):73-8. doi: 10.1111/pace.12243. Epub 2013 Aug 26.
• 7)Radiofrequency catheter ablation for the treatment of idiopathic premature ventricular contractions originating from the right
ventricular outflow tract: a systematic review and meta-analysis. Lamba J1, Redfearn DP, Michael KA, Simpson CS, Abdollah
H, Baranchuk A.
• 8) Am J Cardiol. 2013 Oct 15;112(8):1263-70. doi: 10.1016.Meta-analysis of ventricular premature complexes and their relation to
cardiac mortality in general populations.Ataklte F1, Erqou S, Laukkanen J, Kaptoge S.
• 9) Cleve Clin J Med. 2013 Jun;80(6):377-87. doi: 10.3949/ccjm.80a.12168.Evaluation and management of premature ventricular
complexes.Cantillon DJ1.