Current guidelines suggest evaluating patients with premature ventricular contractions (PVCs) and associated risk factors for underlying coronary artery disease (strength of recommendation [SOR]: C, expert opinion)

Langlois, John P.

Nobles, Michelle B.

Stigleman, Sue

University of Missouri: MOspace

CLINICAL INQUIRIES From the Family Physicians Inquiries Network VOL 57, NO 5 / MAY 2008 325www.jfponline.comFAST TRACKFrequent PVCs are linked to acute MI and sudden death in patients without known coronary artery diseaseMichelle B. Nobles, MD, and John P. Langlois, MDMountain Area Health Education Center Geriatric Medicine Fellowship, Asheville, NCSue Stigleman, MLSMountain Area Health Education Center Health Sciences Library, Asheville, NCShould you evaluate for CAD in seniors with premature ventricular contractions?   Evidence-based answerYes. Current guidelines suggest evaluating patients with premature ventricular contractions (PVCs) and associated risk factors for underlying coronary artery disease (strength of recommendation [SOR]: C, expert opinion).  Frequent PVCs are associated with acute myocardial infarction and sudden death in patients without known coronary artery disease (CAD). They are linked to increased mortality from all causes in elderly patients with a history of CAD, left ventricular dysfunction, hypertension, or valvular heart disease. Frequent PVCs during recovery from exercise stress testing are also associated with increased mortality.  There is strong evidence against suppressing PVCs with antiarrhythmics (SOR: A, randomized controlled trials [RCTs]).Stress preventive measures I fi nd myself discussing PVCs most often with young women who don’t have known heart disease—rather than the elderly. I often discover PVCs on physical examination in the offi ce or see them on a Holter monitor ordered to rule out other more worrisome arrhythmias.  This reminds me that I need to not only consider the issue of treatment aimed at suppressing PVCs (not helpful except when the patient has signifi cant symptoms), but also to consider whether the patient has risk factors for CAD.  In future discussions with patients about PVCs, I plan to shift the focus to measures to prevent CAD—specifi cally tobacco cessation, weight management, daily physical activity, and a healthy diet.  Jennifer Lochner, MDOregon Health and Sciences University, PortlandClinical commentary❚ Evidence summary A consistent defi nition of frequent PVCs doesn’t exist in the literature. Some stud-ies have found a signifi cant risk of death or acute myocardial infarction associated with >30 PVCs per hour.1,2 The 2006 American College of Cardiology/Ameri-can Heart Association/European Society of Cardiology guideline defi nes frequent PVCs as >10 per hour.3 Despite the association between fre-quent PVCs and increased risk of death and cardiac events, our review didn’t fi nd studies that indicate the utility of evaluation strategies for higher-risk patients.C O N T I N U E DCopyright® Dowden Health Media  For personal use onlyFor mass reproduction, content licensing and permissions contact Dowden Health Media.FAST TRACKCLINICAL INQUIRIES326 VOL 57, NO 5 / MAY 2008  THE JOURNAL OF FAMILY PRACTICEFrequent PVCs predict increased mortality The Framingham study looked at the prognostic implications of frequent PVCs (>30 per hour) in a cohort of symptom-atic patients examined over a 6-year pe-riod.1 Men, but not women, had a signifi -cant increase in all-cause mortality (rela-tive risk [RR]=2.36; 95% confi dence interval [CI], 1.65-3.2) and myocardial infarction or sudden death (RR=2.12; 95% CI, 1.33-3.38). The Copenhagen Holter study of a cohort of healthy pa-tients demonstrated an increased risk of myocardial infarction or cardiovascular death in patients with >30 PVCs per hour (hazard ratio [HR]=2.85, 95% CI, 1.16-7.0).2 Frequent PVCs occurring during recovery from stress testing are also associated with increased mortality. A large prospective cohort study fol-lowed more than 29,000 patients with varying degrees of risk for 5 years. Af-ter adjusting for confounding variables, frequent PVCs (≥7 per minute or more complex ventricular ectopy) during recovery predicted an increased risk of death (HR=1.5; 95% CI, 1.1-1.9). Frequent PVCs arising during exercise stress testing were not associated with increased risk.4Suppressing PVCs is a bad ideaStudies have evaluated whether suppress-ing PVCs with antiarrhythmic agents improves prognosis. Both Cardiac Ar-rhythmia Suppression Trials (CAST I: encainide and fl ecainide; CAST II: mori-cizine) showed that suppressing frequent PVCs signifi cantly increased mortality in the treatment groups.5,6 Recommendations In 2006, the American College of Cardi-ology, American Heart Association, and European Society of Cardiology pub-lished their Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death.3  The TABLE summarizes characteris-tics of patients with PVCs who were at higher risk of underlying cardiac disease and death. All patients with PVCs should have a history and physical examination, electrocardiogram, and electrolyte studies. Higher-risk patients should be considered for further evaluation, including stress test-ing, echocardiography, and ambulatory electrocardiogram (SOR: C, opinion). ■References 1.  Bikkina M, Larson MG, Levy D. Prognostic impli-cations of asymptomatic ventricular arrhythmias: the Framingham heart study. Ann Intern Med. 1992;117:990-996. 2.  Sajadieh A, Nielsen OW, Rasmussen V, et al. Ven-tricular arrhythmias and risk of death and acute myocardial infarction in apparently healthy subjects of age 55 or older. Am J Cardiol. 2006;97:1351-1357.  3.  American College of Cardiology, American Heart Association, European Society of Cardiology. ACC/AHA/ESC 2006 guidelines for management of pa-tients with ventricular arrhythmias and the preven-tion of sudden cardiac death. J Am Coll Cardiol. 2006;48:e247-e346.  4.  Frolkis JP, Pothier CE, Blackstone EH, et al. Fre-quent ventricular ectopy after exercise as a predic-tor of death. N Engl J Med. 2003;348:781-790.  5.  The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and fl ecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406-412.  6.  The Cardiac Arrhythmia Suppression Trial II Inves-tigators. Effect of the antiarrhythmic agent morici-zine on survival after myocardial infarction. N Engl J Med. 1992;327:227-233. There is strong evidence against suppressing PVCs with antiarrhythmicsCharacteristics of patients with PVCs who are at higher risk of cardiac disease/death PATIENT CHARACTERISTICS LOWER RISK HIGHER RISKMorphology Unifocal PVCs<10 PVCs per hourComplex multifocal PVCsVentricular tachycardiaVentricular fi brillation>10 PVCs per hourSymptoms Asymptomatic PalpitationsPresyncopeSyncopePreexisting conditionsNone Known history of CADStructural heart disease  Valvular heart disease  CardiomyopathyCAD, coronary artery disease, PVCs, premature ventricular contractions.Source: American College of Cardiology et al.3TABLE

Should you evaluate for CAD in seniors with premature ventricular contractions?

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