Premature Ventricular Complexes (PVCs)
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Introduction

Premature Ventricular Complexes – PVCs (aka ventricular ectopic beats – VEBs) are a common, and usually (but not always) benign cardiac rhythm abnormality.

PVCs may present with palpitations, although many cases are asymptomatic.

  • Palpitations are often intermittent and brief
  • May cause a great deal of anxiety for patients

Beware of patients with syncopal episodes or palpitations (or syncope) associated with exercise.

Most patients can be managed with simple reassurance. Beta-blockers, or calcium channel blockers (second line) can reduced symptomatic episodes.

Terminology

There are a lot of names for the same condition:

  • PVC = VEB = ventricular ectopic = ventricular extrasystole
  • Bigeminy – refers to a scenario where every normal contraction is followed by a PVC
  • Trigeminy – every 3rd contraction is a PVC
  • Couplet – two PVC consecutively
  • Non-sustained Ventricular Tachycardia – NSVT – 3 or more consecutive PVCs

Pathology

A PVC is an electrical stimulus of the ventricles which occurs within the ventricles themselves – i.e. it does not come from the atria.

  • They originate from an ‘ectopic’ (i.e. not the usual place) location in the ventricles
  • Caused by groups of pacemaker cells throughout the conduction system that start to operate independently of the normal stimulation
  • They can be classified as:
    • Unifocal – every PVC appears identical – all arise from he same ectopic location
    • Multifocal – different PVC morphologies – indicated multiple ectopic sites

Other types of ectopic also exist:

  • Atrial ectopics
  • Junctional ectopics

Causes

Diagnosis

A PVC can be discerned on ECG by:

  • Absence of P wave before the QRS
  • Wider, taller QRS complex (>120ms)
  • Often immediately follows a T wave
  • Has a discordant T wave (T wave point in opposite direction to major portion of QRS)

Usually, one or more PVCs will be visible on an ECG – even if the patient is asymptomatic at the time of presentation

  • Consider 24-hour ECG (Holter Monitor) if normal ECG at the time of presentation
PVC on ECG
PVC on ECG. Note the widened and roller QRS, and discordant T wave.

 

Bigeminy on ECG
Bigeminy on ECG. Note the widened and taller QRS complex after each normal cycle, and missing p wave before each second complex.

Management

  • Rule out structural heart disease with an echo
    • If present – refer to cardiology
  • Assess for risk of acute cardiac mortality
    • FHx of sudden cardiac death
    • Previous history of syncope?
      • Especially if associated with exercise
    • Increase in palpitations after exercise
  • If all the above is normal:

References

  • Premature Ventricular Complex (PVC)
  • Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
  • Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
  • Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy

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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) currently works as a GP Registrar and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

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