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PVCs : ?Don't Let Your Patient's Heart Weaken From Extra Heart Beats!
Ramil Goel, MD, FHRS discusses PVCs and if asymptomatic PVCs are more likely to result in cardiomyopathy. He examines if monomorphic PVCs are easier to ablate and whether PVC ablation is an effective option for patients unwilling to take medications.
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Learn more about Ramil Goel, MD, FHRS
Ramil Goel, MD, FHRS
Dr. Ramil Goel is a cardiac electrophysiologist at UF Health, and also serves as an assistant professor within the University of Florida's division of cardiovascular medicine. Dr. Goel attended medical school at All-India Institute of Medical Sciences, where he also completed a non-academic residency in the departments of hematology and cardio-thoracic surgery.Learn more about Ramil Goel, MD, FHRS
Transcription:
The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of .25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I’m Melanie Cole and today, we’re discussing premature ventricular contractions. Don’t let your patients’ weaken from extra heart beats. Joining me is Dr. Ramil Goel. He’s an Electrophysiologist at UF Health Shands Hospital and an Assistant Professor in the Division of Cardiology at the University of Florida College of Medicine. Dr. Goel, I’m so glad to have you with us. If you could give us a little working definition of a PVC and tell us a little bit about how common they are.
Ramil Goel, MD, FHRS (Guest): PVCs are extra heart beats coming from the bottom chamber of the heart. So, they are out of sequence heart beats which don’t follow the usual sequence of electrical activation of the heart. I wanted to talk about this topic because I think it is relatively underrecognized and underappreciated, but it can lead to major consequences. I think it’s really important to know, recognize and diagnose these extra heart beats because nowadays, we have the technology, the therapies available to take care of this problem and save our patients in terms of morbidity and mortality.
Host: Thank you for that. So, while sometimes benign, can these types have negative consequences? You mentioned just a little bit briefly before. Tell us some of the complications from untreated PVCs.
Dr. Goel: Untreated PVCs can bother the patient in the dorm of symptoms, palpitations which can sometimes present as sensation of heart beat. Some patients can feel fatigued because their heart is not beating properly when they are having these extra heart beats. So blood circulation is not as good. Sometimes, PVCs can be symptomatic but even in that situation, they are not completely benign. Because if patients have frequent PVCs, they can lead to weakening of the heart muscle also known as cardiomyopathy which can cause heart failure and symptoms of shortness of breath and other features of heart failure.
Host: If they are sometimes asymptomatic, as well, how are they identified? Is there a clinical presentation? Are they found incidentally? Tell us a little bit about the diagnosis and how it’s even made.
Dr. Goel: The diagnosis if these PVCs are asymptomatic, can be challenging and is mostly incidental. A lot of times, they would be caught because a nurse or a doctor notices that the heart rate is not regular and then a subsequent EKG would show PVCs. Or if they have been monitored on a telemetry floor while hospitalized for any reason, that can show PVCs also. But if these PVCs are noted, I think it’s very important for the provider to recognize them, to act upon them and not ignore them because as I mentioned earlier, the asymptomatic PVCs can lead to weakening of the heart muscle and they need to be recognized and treated appropriately.
Host: So, as we’re talking about whether asymptomatic PVCs are more likely to result in cardiomyopathy which you mentioned before; tell us about some of the valuable tools that may be useful for risk stratification for things like sudden cardiac death in patients that have frequent PVCs. Tell us a little bit about what’s important to note when making the diagnosis and what’s exciting now in the field of diagnostics for PVCs?
Dr. Goel: So, PVCs and their relationship with cardiomyopathy is still a very active are of investigation. We do know it can lead to weakening of the heart muscle and we also know from other diseases that a weak heart can lead to sudden cardiac death. Whether PVC related weak heart has the same risk of sudden cardiac death is not known. But it stands to reason that it would have similar effect in terms of risk of sudden cardiac death. But not just sudden cardiac death. We do know that the cardiomyopathy that results from PVCs can produce heart failure like symptoms which is presented as shortness of breath, swelling in the legs. Regardless of the relationship to sudden cardiac death, they need to be addressed and treated aggressively in most patients.
You asked about what’s important with regards to investigation and what’s new in terms of treatment. So investigation usually begins with figuring out how many extra heart beats a particular patient is having. Are they occasional, how frequent are those? Because it has a direct bearing on what sort of response the heart would develop to those PVCs. If they are very frequent, we know that the heart is more likely to develop weakening. In terms of assessment, we also do echocardiogram to see what is the function of the heart, the structure of the heart. We also like to sometimes on very [00:04:59] instances, do a cardiac MRI to look for any irreversible changes that may have occurred from the PVCs.
And in terms of therapy, we have a very long list of drugs that we can use but much more exciting is the use of cardiac ablation. So, the drugs have modest efficacy and some of them are associated with side effects. But we now, in this day and age have very good techniques by which we can get to the source of a lot of these PVCs using a catheter based approach. So, there’s no open heart surgery involved. Catheters which go through a groin just like with atrial fibrillation ablation procedures, we can hone in at the source of these extra heart beats in the bottom chamber and ablate them mostly with radiofrequency energy.
Host: How do you determine the target site for ablation? Does that depend on the mechanism of the arrythmia? Tell us how you are using activation mapping and how this all works.
Dr. Goel: So, you are now getting into the details of how we find out where the PVCs are coming from and how we ablate them. So, the most critical part of successful ablation of the PVCs is trying to get to the exact location in the heart where these PVCs are coming from. And you mentioned activation mapping. That is basically creating a map of the heart and seeing the earliest point of activation during a PVC. So, if we can find the earliest point of the heart activation during a PVC; we are very close to the source of those PVCs and once we have identified it, tagged it, we can go in with our ablation catheter and ablate in that area using radiofrequency ablation techniques and we are able to get rid of these PVCs. In some instances, there is a very high success rate. The technology is fairly advanced and it’s getting better with every passing year. We use a whole host of imaging and mapping techniques. We use technologies like intracardiac echocardiogram. We use electro-anatomical mapping to create a shell of the endocardial anatomy as well as overlay activation sequencing upon that shell.
So, we have very advanced technology available to us right here at the UF with very highly trained personnel to use this technology to deliver very good results for our patients.
Host: Doctor, as we’re talking a little bit about the management algorithm, tell us about patient selection as well. Is there anyone for whom this is contraindicated? Speak about the selection criteria, who should or who should not be treated with ablation.
Dr. Goel: So, ablation is probably not for everybody. You are pointing in the right direction there that everybody should not undergo ablation. Generally, we usually try a trial of antiarrhythmic drugs. If that is successful, ablation can be deferred. But in a lot of our patients, antiarrhythmic drugs may not be effective. And those are the patients who may benefit from ablation.
Backing off a little bit, not everybody with PVCs necessarily needs treatment. We can very commonly have a situation of a patient having relatively frequent PVCs but no symptoms and no signs of cardiomyopathy. So that means their PVCs don’t cause any heart damage and are not associated with any symptoms. And most available data suggests that we can watch and conservatively manage these patients. We don’t necessarily have to actually treat these PVCs.
Once we have made the decision to treat the PVCs, because of symptoms or because of cardiomyopathy coming from the PVCs; the next step is how do we treat them. Do we treat them with medications, or do we treat it with ablation? And in general, most practitioners would give a trial of medications first and if that fails, ablation would be the next step. However, that also depends on patient preference. Some patients don’t like to take medications especially if they have to be taken chronically. And I know a few younger patients of mine who have preferred ablation as a first line of treatment. And then there is the other spectrum of patients, very frail, elderly patients with a lot of comorbidities who are not felt to be a good risk for ablation procedures. In those patients, we would try to push medications as much as possible. So, there’s a whole gamut of different approaches that we can take once we have decided these PVCs need to be treated.
Host: There certainly is and as we’re talking about those therapies, you mentioned the watchful waiting. Are their lifestyle or potential triggers that you’d like other providers to know if they are a primary care provider working with a patient that has PVCs; do you want them to be counseling their patients on avoiding these triggers such as stress, or alcohol, caffeine, any of those things?
Dr. Goel: Occasionally we can have patients whose PVCs are more frequent when they have some sort of stimulation like with intake of coffee, with intake of alcohol. The new energy drinks which are very common in the market these days can also trigger these extra heart beats. So, I think it is helpful for both primary care physicians and providers along with the patients we know about this, stress can also occasionally cause more PVCs. In general, the conservative measures are always a good idea. Alcohol is known to be a toxin to the heart, so it’s also a good idea to avoid alcohol as much as possible in a patient who is having PVCs. But again, the efficacy of these nonpharmacologic approaches may be modest. They may not be that great. And I think most patients would end up requiring some sort of additional pharmacologic therapy or ablation to get rid of the PVCs.
Host: As we wrap up and you’ve given us such great information today Dr. Goel; please tell other physicians what you’d like them to know about PVCs and when you feel it’s important that they refer to the specialists at UF Health Shands Hospital.
Dr. Goel: So, I believe that this should first of all, be recognized and primary care physicians and providers should be looking out for EKG signs or of patient symptoms which may suggest presence of PVCs. Not only because it can lead to potential harm to the patient in future, but also because we have therapies both in the form of medications and ablation to take care of these PVCs and potentially avoid bad long term effects of these PVCs. So, I think it’s very important that having a high suspicion for these PVCs is paramount.
The other step would be the next set of investigations which may include a Holter recording to calculate or estimate the number of extra heart beats the patient is having in the course of a day, along with simple investigations like echocardiogram to assess the current structure and function of the heart and referral to the EP provider so that the patient can be offered all the potential therapies and options for them which are available for addressing the PVCs.
Host: Thank you so much Dr. Goel for joining us today and sharing your expertise for other providers. To refer your patient please visit www.ufhealth.org/heart. Or to learn more about other healthcare topics at UF Health Shands Hospital, you can visit www.ufhealth.org/medmatters to get connected with one of our providers. And that concludes today’s episode of UF Health MedEd Cast with UF Health Shands Hospital. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I’m Melanie cole.
The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of .25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I’m Melanie Cole and today, we’re discussing premature ventricular contractions. Don’t let your patients’ weaken from extra heart beats. Joining me is Dr. Ramil Goel. He’s an Electrophysiologist at UF Health Shands Hospital and an Assistant Professor in the Division of Cardiology at the University of Florida College of Medicine. Dr. Goel, I’m so glad to have you with us. If you could give us a little working definition of a PVC and tell us a little bit about how common they are.
Ramil Goel, MD, FHRS (Guest): PVCs are extra heart beats coming from the bottom chamber of the heart. So, they are out of sequence heart beats which don’t follow the usual sequence of electrical activation of the heart. I wanted to talk about this topic because I think it is relatively underrecognized and underappreciated, but it can lead to major consequences. I think it’s really important to know, recognize and diagnose these extra heart beats because nowadays, we have the technology, the therapies available to take care of this problem and save our patients in terms of morbidity and mortality.
Host: Thank you for that. So, while sometimes benign, can these types have negative consequences? You mentioned just a little bit briefly before. Tell us some of the complications from untreated PVCs.
Dr. Goel: Untreated PVCs can bother the patient in the dorm of symptoms, palpitations which can sometimes present as sensation of heart beat. Some patients can feel fatigued because their heart is not beating properly when they are having these extra heart beats. So blood circulation is not as good. Sometimes, PVCs can be symptomatic but even in that situation, they are not completely benign. Because if patients have frequent PVCs, they can lead to weakening of the heart muscle also known as cardiomyopathy which can cause heart failure and symptoms of shortness of breath and other features of heart failure.
Host: If they are sometimes asymptomatic, as well, how are they identified? Is there a clinical presentation? Are they found incidentally? Tell us a little bit about the diagnosis and how it’s even made.
Dr. Goel: The diagnosis if these PVCs are asymptomatic, can be challenging and is mostly incidental. A lot of times, they would be caught because a nurse or a doctor notices that the heart rate is not regular and then a subsequent EKG would show PVCs. Or if they have been monitored on a telemetry floor while hospitalized for any reason, that can show PVCs also. But if these PVCs are noted, I think it’s very important for the provider to recognize them, to act upon them and not ignore them because as I mentioned earlier, the asymptomatic PVCs can lead to weakening of the heart muscle and they need to be recognized and treated appropriately.
Host: So, as we’re talking about whether asymptomatic PVCs are more likely to result in cardiomyopathy which you mentioned before; tell us about some of the valuable tools that may be useful for risk stratification for things like sudden cardiac death in patients that have frequent PVCs. Tell us a little bit about what’s important to note when making the diagnosis and what’s exciting now in the field of diagnostics for PVCs?
Dr. Goel: So, PVCs and their relationship with cardiomyopathy is still a very active are of investigation. We do know it can lead to weakening of the heart muscle and we also know from other diseases that a weak heart can lead to sudden cardiac death. Whether PVC related weak heart has the same risk of sudden cardiac death is not known. But it stands to reason that it would have similar effect in terms of risk of sudden cardiac death. But not just sudden cardiac death. We do know that the cardiomyopathy that results from PVCs can produce heart failure like symptoms which is presented as shortness of breath, swelling in the legs. Regardless of the relationship to sudden cardiac death, they need to be addressed and treated aggressively in most patients.
You asked about what’s important with regards to investigation and what’s new in terms of treatment. So investigation usually begins with figuring out how many extra heart beats a particular patient is having. Are they occasional, how frequent are those? Because it has a direct bearing on what sort of response the heart would develop to those PVCs. If they are very frequent, we know that the heart is more likely to develop weakening. In terms of assessment, we also do echocardiogram to see what is the function of the heart, the structure of the heart. We also like to sometimes on very [00:04:59] instances, do a cardiac MRI to look for any irreversible changes that may have occurred from the PVCs.
And in terms of therapy, we have a very long list of drugs that we can use but much more exciting is the use of cardiac ablation. So, the drugs have modest efficacy and some of them are associated with side effects. But we now, in this day and age have very good techniques by which we can get to the source of a lot of these PVCs using a catheter based approach. So, there’s no open heart surgery involved. Catheters which go through a groin just like with atrial fibrillation ablation procedures, we can hone in at the source of these extra heart beats in the bottom chamber and ablate them mostly with radiofrequency energy.
Host: How do you determine the target site for ablation? Does that depend on the mechanism of the arrythmia? Tell us how you are using activation mapping and how this all works.
Dr. Goel: So, you are now getting into the details of how we find out where the PVCs are coming from and how we ablate them. So, the most critical part of successful ablation of the PVCs is trying to get to the exact location in the heart where these PVCs are coming from. And you mentioned activation mapping. That is basically creating a map of the heart and seeing the earliest point of activation during a PVC. So, if we can find the earliest point of the heart activation during a PVC; we are very close to the source of those PVCs and once we have identified it, tagged it, we can go in with our ablation catheter and ablate in that area using radiofrequency ablation techniques and we are able to get rid of these PVCs. In some instances, there is a very high success rate. The technology is fairly advanced and it’s getting better with every passing year. We use a whole host of imaging and mapping techniques. We use technologies like intracardiac echocardiogram. We use electro-anatomical mapping to create a shell of the endocardial anatomy as well as overlay activation sequencing upon that shell.
So, we have very advanced technology available to us right here at the UF with very highly trained personnel to use this technology to deliver very good results for our patients.
Host: Doctor, as we’re talking a little bit about the management algorithm, tell us about patient selection as well. Is there anyone for whom this is contraindicated? Speak about the selection criteria, who should or who should not be treated with ablation.
Dr. Goel: So, ablation is probably not for everybody. You are pointing in the right direction there that everybody should not undergo ablation. Generally, we usually try a trial of antiarrhythmic drugs. If that is successful, ablation can be deferred. But in a lot of our patients, antiarrhythmic drugs may not be effective. And those are the patients who may benefit from ablation.
Backing off a little bit, not everybody with PVCs necessarily needs treatment. We can very commonly have a situation of a patient having relatively frequent PVCs but no symptoms and no signs of cardiomyopathy. So that means their PVCs don’t cause any heart damage and are not associated with any symptoms. And most available data suggests that we can watch and conservatively manage these patients. We don’t necessarily have to actually treat these PVCs.
Once we have made the decision to treat the PVCs, because of symptoms or because of cardiomyopathy coming from the PVCs; the next step is how do we treat them. Do we treat them with medications, or do we treat it with ablation? And in general, most practitioners would give a trial of medications first and if that fails, ablation would be the next step. However, that also depends on patient preference. Some patients don’t like to take medications especially if they have to be taken chronically. And I know a few younger patients of mine who have preferred ablation as a first line of treatment. And then there is the other spectrum of patients, very frail, elderly patients with a lot of comorbidities who are not felt to be a good risk for ablation procedures. In those patients, we would try to push medications as much as possible. So, there’s a whole gamut of different approaches that we can take once we have decided these PVCs need to be treated.
Host: There certainly is and as we’re talking about those therapies, you mentioned the watchful waiting. Are their lifestyle or potential triggers that you’d like other providers to know if they are a primary care provider working with a patient that has PVCs; do you want them to be counseling their patients on avoiding these triggers such as stress, or alcohol, caffeine, any of those things?
Dr. Goel: Occasionally we can have patients whose PVCs are more frequent when they have some sort of stimulation like with intake of coffee, with intake of alcohol. The new energy drinks which are very common in the market these days can also trigger these extra heart beats. So, I think it is helpful for both primary care physicians and providers along with the patients we know about this, stress can also occasionally cause more PVCs. In general, the conservative measures are always a good idea. Alcohol is known to be a toxin to the heart, so it’s also a good idea to avoid alcohol as much as possible in a patient who is having PVCs. But again, the efficacy of these nonpharmacologic approaches may be modest. They may not be that great. And I think most patients would end up requiring some sort of additional pharmacologic therapy or ablation to get rid of the PVCs.
Host: As we wrap up and you’ve given us such great information today Dr. Goel; please tell other physicians what you’d like them to know about PVCs and when you feel it’s important that they refer to the specialists at UF Health Shands Hospital.
Dr. Goel: So, I believe that this should first of all, be recognized and primary care physicians and providers should be looking out for EKG signs or of patient symptoms which may suggest presence of PVCs. Not only because it can lead to potential harm to the patient in future, but also because we have therapies both in the form of medications and ablation to take care of these PVCs and potentially avoid bad long term effects of these PVCs. So, I think it’s very important that having a high suspicion for these PVCs is paramount.
The other step would be the next set of investigations which may include a Holter recording to calculate or estimate the number of extra heart beats the patient is having in the course of a day, along with simple investigations like echocardiogram to assess the current structure and function of the heart and referral to the EP provider so that the patient can be offered all the potential therapies and options for them which are available for addressing the PVCs.
Host: Thank you so much Dr. Goel for joining us today and sharing your expertise for other providers. To refer your patient please visit www.ufhealth.org/heart. Or to learn more about other healthcare topics at UF Health Shands Hospital, you can visit www.ufhealth.org/medmatters to get connected with one of our providers. And that concludes today’s episode of UF Health MedEd Cast with UF Health Shands Hospital. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I’m Melanie cole.