Transcript Supplemental Content - Annals of Internal Medicine

From the Publishers of
Are Those Ventricular Premature
Contractions Really Benign ?
COPYRIGHT © 2016, ALL RIGHTS RESERVED
Terms of Use
The Consult Guys® slide sets are owned and copyrighted by the American College
of Physicians (ACP). All text, graphics, trademarks, and other intellectual property
incorporated into the slide sets remain the sole and exclusive property of ACP.
The slide sets may be used only by the person who downloads or purchases them
and only for the purpose of presenting them during not-for-profit educational
activities. Users may incorporate the entire slide set or selected individual slides
into their own teaching presentations but may not alter the content of the slides in
any way or remove the ACP copyright notice.
Users may make print copies for use as hand-outs for the audience the user is
personally addressing but may not otherwise reproduce or distribute the slides by
any means or media, including but not limited to sending them as e-mail
attachments, posting them on Internet or Intranet sites, publishing them in meeting
proceedings, or making them available for sale or distribution in any unauthorized
form, without the express written permission of the ACP. Unauthorized use of the
Consult Guys® slide sets constitutes copyright infringement.
Copyright © 2016
Copyright © 2016
Copyright © 2016
*Reproduced with Permission from Howard Weitz, MD
Patient
 Frequent VPCs noted during evaluation of “awareness” of




the heartbeat.
Structurally normal heart
 Normal left ventricular function
 Normal valves
No inducible ischemia, no scar
A structurally normal heart
VPCs decreased during stress test
Copyright © 2016
73 asymptomatic healthy patients
Harold L. Kennedy, M.D., M.P.H., James A. Whitlock, B.S., Michael K. Sprague, Lisa J. Kennedy, Thomas A.
Buckingham, M.D., and Robert J. Goldberg, Ph.D. Long-Term Follow-up of Asymptomatic Healthy Subjects with
Frequent and Complex Ventricular Ectopy
N Engl J Med 1985; 312:193-197. DOI: 10.1056/NEJM198501243120401
VPCs
 Frequent VPCs
More than 60 VPC / hour
 Range 78-1994 VPC / hour
 Complex ventricular ectopy (75%)
 Couplets
 Bigeminy
 Multifocal VPCs
 Non sustained Vtach (up to 16 beats)

Copyright © 2016
No evidence heart disease
 Echo
 Maximal exercise treadmill test
 Coronary angio (31 patients) if suspicious for CAD
Copyright © 2016
73 asymptomatic healthy patients
Long term prognosis similar to the healthy population
*From The New England Journal of Medicine, Harold L. Kennedy, James A. Whitlock, Michael K. Sprague, et al),
Long-Term Follow-up of Asymptomatic Healthy Subjects with Frequent and Complex Ventricular Ectopy, 312, 193197 Copyright ©1985 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical
Society.
• 15,000 patients
• ECG rhythm strip 2 minutes
• 11 year follow up
• Presence of VPC indicated 2X risk of CHD event, fatal CHD,
death in subjects without known CHD or CHD risk factors
- No exhaustive investigation to rule out structural heart disease
*Massing, Mark W. et al. Usefulness of Ventricular Premature Complexes to Predict Coronary Heart Disease Events
and Mortality (from the Atherosclerosis Risk In Communities Cohort). American Journal of Cardiology. 2006; 12:1609 –
1612.
*Reprinted from American Journal of Cardiology, 98/12, Mark W. Massing,Ross J. Simpson,Pentti M. Rautaharju,Pamela J.
Schreiner,Richard Crow,Gerardo Heiss, Usefulness of Ventricular Premature Complexes to Predict Coronary Heart Disease
Events and Mortality (from the Atherosclerosis Risk In Communities Cohort), 1609-1612, 2006, with permission from Elsevier.
*Reprinted from American Journal of Cardiology, 98/12, Mark W. Massing,Ross J. Simpson,Pentti M. Rautaharju,Pamela J.
Schreiner,Richard Crow,Gerardo Heiss, Usefulness of Ventricular Premature Complexes to Predict Coronary Heart Disease
Events and Mortality (from the Atherosclerosis Risk In Communities Cohort), 1609-1612, 2006, with permission from Elsevier.
*Lee V et al. The prognostic significance of premature ventricular complexes in adults without clinically apparent heart disease:
a meta-analysis and systematic review. Heart. 2012;98:1290-1298. doi:10.1136/heartjnl-2012-302005.
Meta analysis
 The studies are poor
 They probably included patients with heart disease
 Adverse outcome: VPCs and
 Advanced
age
 Cardiac risk factors
 There is no robust study of the clinical significance
of VPCs in the patient with a structurally normal
heart
Copyright © 2016
*Dello Russo, Antonio et al. Concealed cardiomyopathies in competitive athletes with ventricular arrhythmias and an
apparently normal heart: role of cardiac electroanatomical mapping and biopsy. Heart Rhythm. 2011;12:1915 –
1922.
Heart Rhythm
 13 competitive athletes
 Frequent VPCs
 Normal heart
Exam
 Transthoracic echo
 Cardiac MRI
 Subsequently electrophysiologic testing and biopsy
 12 of 13 with either focal cardiomyopathy or myocarditis

Norman Jeff Holter
© The European Society of Cardiology 2006
Reproduced with Permission from Oxford University Press.
*This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.
Our approach to the healthy patient with
symptomatic VPCs
 Evaluate the patient
 Document and quantitate the VPCs
Copyright © 2016
Our approach to the healthy patient with symptomatic
VPCs
 Evaluate the patient
 Document and quantitate the VPCs
 Look for structural heart disease
 Transthoracic echo
 Look for myocardial ischemia (stress test)
 Coronary artery disease risk factors
 VPCs with exercise
 Advanced imaging (CT, MRI) if indicated
Copyright © 2016
*Cha YM et al. Premature Ventricular Contraction-Induced Cardiomyopathy A Treatable Condition. Circulation:
Arrhythmia and Electrophysiology. 2012; 5: 229-236 doi: 10.1161/CIRCEP.111.963348
VPC Mediated Cardiomyopathy
 High VPC burden (15-20% of all beats)
 No obvious cause
 VPC ablation?
Let’s call an expert!
Reginald Ho, MD
Copyright © 2016
Summary
 Studies that have looked at the prognosis of VPCs with
structurally normal hearts are flawed and incomplete

No exhaustive search for structural heart disease
 Document and quantitate the VPCs
 Search for causes for VPCs
 Echocardiogram to search for structural abnormality
 Treadmill stress test if at risk for CAD or vpcs increase with
activity
 Be aware of VPC induced cardiomyopathy – it is reversible
Copyright © 2016
Produced by
and
Copyright © 2016
COPYRIGHT © 2016, ALL RIGHTS RESERVED