By Claudio López Bruzual MD
What to do with those patients when we detect monomorphic Premature Ventricular Contractions (PVCs ) on the ECG?
There are two reasons why patients with PVCs usually seek professional care: first, they have symptoms (irregular palpitations, presyncope, dyspnea or fatigue). The second is precisely the topic we will talk about here: the physician detected monomorphic contractions on an EKG.
12-lead EKG
To evaluate a patient, the first is to perform a 2 minute, 12-lead EKG. This allows us an adequate observation of the QTc, as well as the morphology of the PVC (to appreciate its place of origin within the heart) and is a useful test to discard other pathologies such as:
- Brugada syndrome. Characterized by Right Bundle Branch Block, persistent ST segment elevation, and sudden death
- Presence of scars evidenced by pathological Q waves. It should be remembered that one of the conditions for such waves to be considered pathological is that they occur in leads where there is normally no Q.
- Conduction disorders. Such as tachyarritmias, for instance.
6-day holter
Although for a long time the 24-h Holter was considered the gold standard for analyzing the rate of Premature Ventricular Contractions, recent evidence suggests there might be substantial variations. Therefore, it is advisable a continuous evaluation for 6 days to be able to estimate the number of PVCs, and thus, be able to establish a relationship between them and the number of sinus beats in the same period. This will offer important information.
Gather information
In addition to the aforementioned tests, it is necessary gathering information about accompanying symptoms, and history of heart disease, both, personal and family. The physician should inquire about relatives in the first degree who have presented sudden or premature deaths, since this type of history increases the suspicion of arrhythmogenic dysplasia of the right ventricle or cardiomyopathy.
Likewise, as part of the patient evaluation, an echocardiogram should always be performed to rule out structural disease or decrease in LV ejection fraction that could be contributing to the genesis of PVCs or making them more evident.
Summarizing, it is required to extract all possible information regarding the accompanying symptoms, the intensity of the problem expressed as % of PVC, related to the total number of beats and the presence or absence of structural heart disease.
