Ventricular ectopic beats (VEBs) are common. Frequent (>60/hr or 1/min) in healthy subjects has an estimated prevalence of one to four percent in the general population. Over 10 percent on a Holter monitor is considered a high VEB burden. Monomorphic VEBs represent a focal arrhythmia arising from a single site. Generally, individuals with frequent monomorphic premature ventricular contractions (PVCs) have a benign clinical course. A portion have bothersome symptoms cardiomyopathy can develop in a minority of cases.
The clinical presentation of patients with frequent VEBs is variable. A large proportion are asymptomatic and are discovered on a routine ECG or during monitoring for an unrelated procedure. Other patients are mistaken to be bradycardic by palpation of the pulse and are referred for investigation based on this.
Individuals can be highly symptomatic complaining of palpitations, ‘missed beats’, ‘heavy beats’ and fluttering in the chest. Tiredness, dyspnoea, light-headedness and mental clouding are other common complaints. Heart failure symptoms may be the initial presentation.
Indications for treatment
The majority of individuals with frequent VEBs have a benign clinical course. A small proportion of individuals with a high burden of ventricular ectopy can develop left ventricular dysfunction and an even smaller proportion, VEB induced polymorphic ventricular tachycardia.
As such the indications for treatment include high symptom burden, VEB induced cardiomyopathy and rarely PVC induced polymorphic VT.
It is important to identify the those with structural abnormalities.
A 12 lead ECG is helpful to confirm the morphology and location of the VEB as well as to look for other evidence of structural heart disease such as Q waves, T wave inversion and epsilon waves anteriorly, suggestive of arrhythmogenic right ventricular dysplasia(ARVD).
Echocardiography assesses structure and function.
A 24-hour Holter can quantify the burden and to see whether there is more than one morphology.
Cardiac MRI may be warranted if there is any evidence of a wall motion abnormality, an abnormal ECG or multiple morphologies of PVCs making structural heart disease more likely.
Given the small incidence of PVC induced cardiomyopathy clinical surveillance is appropriate even for asymptomatic patients.
In individuals with a high burden of symptomatic VEBs or individuals with evidence of VEB induced cardiomyopathy, treatment is recommended.
Beta blockers or calcium channel blockers remain first line options. Flecainide (once ischemia and abnormal LV function had been excluded) or sotalol are second line.
Catheter ablation with the aid of 3D mapping has a high success rate. It is generally reserved for patients who either cannot tolerate medical therapy or have failed medical therapy. The procedural risk is relatively low, and the curative rates are high.
- Frequent monomorphic VEBs are common. The vast majority have a benign c course.
- In high symptomatic burden or with evidence of VEB induced cardiomyopathy there are safe, effective therapies.
- Ongoing clinical surveillance is important in conservatively managed asymptomatic individuals
References available on request.
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Author competing interests: nil
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