The European Journal of General Practice

ISSN: 1381-4788 (Print) 1751-1402 (Online) Journal homepage: http://www.tandfonline.com/loi/igen20

Are premature ventricular contractions always

harmless?

R. A. G. Winkens, P. F. Höppener, J. A. Kragten, M. P. Verburg & H. F. J. M.

Crebolder

To cite this article: R. A. G. Winkens, P. F. Höppener, J. A. Kragten, M. P. Verburg & H. F. J. M.

Crebolder (2014) Are premature ventricular contractions always harmless?, The European Journal
of General Practice, 20:2, 134-138, DOI: 10.3109/13814788.2013.859243

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Published online: 28 Nov 2013.

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European Journal of General Practice, 2014; 20: 134–138

Clinical Lesson

Are premature ventricular contractions always harmless?

R. A. G. Winkens1,2, P. F. Höppener2, J. A. Kragten3, M. P. Verburg4 & H. F. J. M. Crebolder2

1DiagnosticCentre, Department of Integrated Care, Maastricht University Medical Centre, the Netherlands,
2Department of Primary Care, Maastricht University, the Netherlands, 3Department of Cardiology, Atrium Medical Centre,
Heerlen, the Netherlands, and 4Department of Anaesthesiology, Atrium Medical Centre, Heerlen, the Netherlands

KEY MESSAGE:

• The load of premature ventricular contractions (PVCs) can be detected by Holter or event recording.
• More frequent PVCs may lead to fatigue or exertional dyspnoea.
• PVCs are only harmless when they occur incidentally, i.e. in less than 1% of heartbeats.

ABSTRACT
Introduction: Premature ventricular contractions (PVCs) are among the most prevalent arrhythmias. PVCs lead to haemodynamically
insufficient heartbeats. Their presence is considered rather insignificant, but this widespread assumption is not supported by
research evidence.
Cases: We present three cases of patients commonly seen in daily general practice, with a range of presentations, varying from
incidental (harmless) PVCs to frequent and potentially symptomatic PVCs.
Discussion: In more frequent PVCs (⬎ 10% heart beats) fatigue and exertional dyspnoea may occur. When ⬎ 20% of heart beats are
PVCs, patients may develop cardiomyopathy and heart failure. Incidental PVCs are harmless. Anti-arrhythmic drug treatment should
be considered in case of frequent PVCs but also catheter ablation appears an effective treatment option.
Conclusion: Altogether, PVCs may not be harmless, depending on their occurrence rate. Research data from primary care settings
on epidemiology and natural course is needed.

Keywords: premature ventricular contractions, fatigue, exertional dyspnoea

INTRODUCTION PVCs are quite common. Incidental PVCs are reported

A premature ventricular contraction (PVC), also known
as a ventricular extra systole, is a common, if not
the most common, arrhythmia (1–4). PVCs may cause
symptoms such as irregular heartbeats, palpitations or
gaps in a, usually regular, pulse rhythm. Repeatedly, this
results in fear of a serious heart condition in patients (1).
Each PVC is followed by a compensatory electrical pause
(Figure 1). This may be felt as palpitation or a gap in the
pulse rate.
The general assumption among GPs is that PVCs are
usually harmless and clinically less relevant. This assump-
tion has been the rule for many years and is postulated
in the medical literature, both in books and scientific
journals (4–7). Literature reveals no publications in which
harmlessness of PVCs is confirmed or explained.
as being most frequent in the general population
(1,3,4,8). In the age group of 45–65 years prevalence, is
roughly 6% and increases with age (9). The prevalence
of frequent instead of incidental PVCs in the open
population is, however, unknown. Literature often
reveals data on selected cases in specific patient groups,
resulting in higher prevalence.
PVCs often arise from a pre-excitation, mostly in the
right ventricle. Such an abnormal excitation may occur
in the myocardium of healthy people, even without cardiac
abnormalities. Remainders of embryonic tissue may
become electrically active and then lead to pre-excitation.
PVCs may also be caused by myocardial damage
(ischaemia, trauma), valvular disorders, hypertension,
thyroid function disorders or drugs (e.g. anti-arrhythmics).

Correspondence: Ron A. G. Winkens, Diagnostic Centre MUMC, Department of Integrated Care, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht,
the Netherlands. E-mail: ron.winkens@maastrichtuniversity.nl

(Received 1 June 2012; accepted 9 October 2013)

ISSN 1381-4788 print/ISSN 1751-1402 online © 2014 Informa Healthcare
DOI: 10.3109/13814788.2013.859243

Figure 1. Example of PVCs found in a routine electrocardiography.
These possible causes of PVCs should be considered
during history taking, physical examination and ECG,
together with risk factors such as a family history of
sudden cardiac death or heart disease and the age of
the patient. When risk factors or possible causes are
present in a patient with PVCs, they could merit referral
to a cardiologist. Erroneously, tobacco and coffee are
sometimes held accountable (1). An explanation of the
possible haemodynamic consequences of PVCs is shown
in the following examples.
CASE DESCRIPTIONS
Patient A
Patient A is a man aged 63 who presented to his GP with
symptoms of exertional dyspnoea, fatigue and palpita-
tions. The medical history revealed type 2 diabetes,
hypertension and a mild hypercholesterolemia. Drug
use: metoprolol, perindopril, metformin and simvasta-
tin. At physical examination, a blood pressure of 125/75
was found and an irregular pulse rate of 54 per minute.
Subsequent electrocardiography showed a heart rate of
62 beats per minute, including 12 PVCs per minute.
The patient was referred to a cardiologist because,
based on the clinical presentation, the GP considered the
presence of heart failure. Additional testing revealed no
heart failure; the metoprolol dose was reduced and
gradually the symptoms disappeared.
Comments. The symptoms of patient A and the response
to lowering the metoprolol dose can be explained
by the haemodynamic consequences of PVCs. The
abnormal excitation leads to a premature and inefficient
contraction, sometimes even in the opposite direction.
Figure 2. Plethysmography of a patient with frequent PVCs. The arrows show the increase of blood flow in the circulation after each left ventricular
contraction. The dotted arrows show the absence of an increased blood flow after a premature ventricular contraction.
Are PVCs harmless? 135
Apart from this, during diastole the ventricles are not
filled completely. The electrical pause after the PVC
prevents the insufficient heartbeat during the PVC from
being followed by a compensational extra heartbeat.
Thus, the haemodynamic deficit of the PVC is not com-
pensated by the next heartbeat. The systolic discharge
is, therefore, reduced as echocardiographically con-
firmed by Zaborska et al., (10). They found that stroke
volume of a PVC was only 26% of the normal stroke
volume during a heartbeat. Therefore, the cardiac out-
put is determined by the pulse rate minus the number
of PVCs each minute. The haemodynamic effects of the
reduced stroke volume of PVCs can be visualized by a
plethysmography. A plethysmograph measures changes
in volume (usually resulting from fluctuations in the
amount of blood or air it contains) within an organ or
vessel. Figure 2 shows a plethysmogram of a 60 year
old healthy patient with PVCs. The plethysmogram
(lower line in Figure 2) shows the absence of increase
in blood flow and artery volume after a PVC, while an
increase is visible after a normal contraction. Patient A
had a heart rate of 62, but due to the 12 PVCs each
minute, the cardiac output of only 50 efficient beats
remained causing the same symptoms as in a brady-
cardia. This is called a mechanical bradycardia (11). By
lowering the metoprolol dose, pulse rate and the
cardiac output increased thereby reducing the dysp-
noea and fatigue. The frequency of PVCs remained
unchanged with still one PVC in five heartbeats.
Patient B
Patient B is a 68 year old woman with symptoms of
periodic irregular heartbeats and palpitations; some-
times she gets dizzy. As a result of a family history of
136 R. A. G. Winkens et al.
heart attacks, she is worried about these symptoms.
At physical examination a pulse rate of 72 was found,
a resting electrocardiography showed five PVCs per
minute, with duplets. The GP explained the extra
systoles and the fact that they are considered harmless
to the patient and consequently reassured her.
Comments. As stated earlier, it is generally assumed
that PVCs are harmless and cause no clinically important
symptoms. Taking into account information in the
previous case, this indeed seems true for this patient.
Here, the patient ’s symptoms can be explained by the
irregularity in the heart rhythm. However, the presence
of frequent PVCs cannot be excluded solely based on a
resting electrocardiography. It requires event recording
or a Holter registration as this provides information on
the percentage of PVCs occurring in 24 h. In patient B,
the palpitations persisted. Ultimately, the GP referred
her for a Holter registration, and this revealed only
incidental PVCs.
Patient C
Patient C is a man aged 57 with no symptoms in whom
very frequent PVCs were found on an electrocardio-
gram, performed during a routine occupational health
check. He was advised to seek further cardiological
analysis. After referral to a cardiologist, a repeated elec-
trocardiography and subsequent Holter revealed a heart
rate of 70 bpm with 20 PVCs (frequently ventricular
bigeminy) each minute. After weighing the pros and
cons of drug treatment versus invasive treatment,
patient C underwent a catheter ablation. As a result, the
PVCs disappeared completely.
Comments. Despite that patient C is asymptomatic, there
is evidence reported in the literature suggesting that fre-
quent PVCs (more than 10% of heartbeats) may result in
cardiomyopathy with an impaired left ventricular func-
tion and heart failure (6,12–16). There are, however,
varying recommendations about when to treat. The
threshold in critical PVC load resulting in treatment var-
ies between 10 and 24% (13,15,17–19). Recent echocar-
diography techniques such as ‘speckle tracking analysis’
suggest that a PVC load of 10% already can lead to car-
diomyopathy (12).
From a haemodynamic viewpoint, the situation in
patient C is quite similar to the situation in patient A.
Therefore, one might expect that patient C would also
have physical complaints but obviously this is dependent
on factors like physical condition, co-morbidity and
the level of physical activity the patient has to perform
(or has adapted to). Although unlikely, it cannot be
excluded that the PVCs in patient A were caused by the
metoprolol treatment.
DISCUSSION
Are PVCs harmless?
While searching the literature for evidence on the
potential consequences of PVCs, we found conflicting
papers on the definition of frequent PVCs (6,12,13,
15–21). Unfortunately, we found no study that directly
compares frequencies of PVCs with the risk of heart
problems. Evidence on clinical consequences of PVCs is
rather scarce, especially from primary care setting.
Studies discussing symptoms due to PVCs are most
often based on hospital data. These studies show
a relation between frequent PVCs and symptoms such
as fatigue and exertional dyspnoea (3,4,6,11–15,17,
18,20,21 ).
There is some evidence showing that PVCs are not
always harmless (3,4,6,11–15,17,18,20,21). In the ACC
guidelines, it is concluded that frequent ventricular
ectopic activity predicts an increased risk of sudden
cardiac death. This conclusion, however, is based on data
from hospital studies among patients with a pre-existing
cardiac problem (22). Other studies have reported a
correlation with tachycardia related cardiomyopathy
(6,11–16,19). A causal relation between PVCs and
cardiomyopathy seems likely as two studies report
improvement of left ventricular function after treating
PVCs through ablation (12,14,15,17–20,23).
Should PVCs be treated?
Until recently, anti-arrhythmic drugs, predominantly
beta-blockers, were considered as the first choice treat-
ment. Unfortunately, they combine effectiveness with
a serious risk of side effects (1,24). Bradycardia is con-
sidered one of the contraindications to initiate beta
blocker treatment (24). Niwano found that PVCs could
not produce an effective cardiac output due to the pre-
mature excitation resulting in a much lower pulse rate.
Patients might lose up to almost a third of the effective
cardiac output and might develop similar conditions as
in sick sinus syndrome or atrioventricular block (25).
Based on evidence reported in the literature, we sug-
gest that there is only an indication for beta-blockers
in case of highly frequent PVCs (more than 10%) in
combination with a heart rate above 70 beats per
minute (11,24–26).
An alternative would be catheter ablation, an inva-
sive procedure in which the origin of the PVCs is directly
treated. With this technique, the locations in the
myocardium that cause the pre-excitation and thus
PVCs are searched for and disabled by heating through
RFCA (Radio Frequent Catheter Ablation) or by freezing
(cryoablation). Effect rates of 70–90% are reported,
but long-term prognosis is not yet known (6,12,14,
15,18,20).

Primary care research?
Although the treatment options are usually applied by
cardiologists, be it drug treatment or ablation, the main
presentation of PVCs occurs in primary care setting, and
PVCs are often noticed as an incidental finding by GPs.
It is in this setting that the initial management decision
is made, either to neglect the PVCs and reassure the
patient, as some studies seem to suffer from the
misapprehension that PVCs are always harmless and,
when desired, can be treated best with beta-blockers or
to take additional diagnostic actions (10,24). Therefore,
the natural course and the consequences of incidence
rates should be studied in primary care settings instead
of in selected cases in specialist settings. A growing
number of GPs has direct access to electrocardiography
and/or event recording in primary care without referral
(27). These instruments offer a first impression whether
PVCs occur and in what frequency.
Suggestions for daily practice
This paper is concerned with patients in a primary care
setting who present with PVCs, irrespective of the pres-
ence of cardiovascular risk factors. Awaiting data from
studies in primary care settings we suggest GPs should
take the information from this paper into account and
not assume the presence of PVCs on electrocardiogra-
phy to be an incidental and meaningless finding. Test
facilities such as Holter techniques or event recording
can be used by GPs to assess the PVC load when PVCs
are found, especially when a patient has symptoms
such as exertional dyspnoea or fatigue. In several parts
of the Netherlands, both Holter and/or event recording
can be ordered by GPs without referral. They are then
performed in the hospital, diagnostic centre or private
institution, and the GP receives the test result together
with an interpretation plus recommendation by a
cardiologist.
Based on the available literature, we consider the
following suggestions for managing PVCs to be helpful in
general practice.
Items to be checked by the GP in cases with frequent
or symptomatic PVCs (1,15):
• myocardial damage (ischaemia, trauma),
• valvular disorders, hypertension, thyroid function
disorders,
• side effects of drugs (e.g. anti-arrhythmics),
• risk factors: age and a family history of (sudden)
heart disease,
• unrelated aspects: tobacco or coffee use.
Reassurance of the patient is justifiable in case of
sporadic and incidental PVCs (less than 1% of heartbeats
as suggested in literature) (7,14,28). Decisions to treat
PVCs appear mainly based on symptoms, interference
Are PVCs harmless? 137
with other treatment (e.g. cardiac resynchronization
therapy), or suspicion of PVC-mediated cardiomyopathy
(28). In our view, pulse rate should also play an impor-
tant role in this decision. Should PVCs occur more fre-
quently or should they be found together with symptoms
such as fatigue or exertional dyspnoea, a 24-h Holter
registration is a reliable assessment of the actual PVC-
load (29). When the PVC-load is more than 10% of all
heartbeats or when a PVC-load of 1–10% is accompanied
by fatigue or exertional dyspnoea, referral to a cardiolo-
gist is recommended (13,15,17,18). The cardiologist
could then perform an analysis of the cause(s) of the
frequent PVCs and decide on the best treatment
option.
Further research in primary care setting is needed to
assess the clinical consequences of PVCs and the value
of various management options.
Conclusion
The assumption that PVCs are always harmless is not
justified. Further research should try to assess in primary
care setting when PVCs may cause harm. Awaiting such
evidence, GPs could consider various management
options for managing PVCs.
The patients whose test results are presented
(anonymously) in this paper gave their approval for
publication.
Declaration of interest: The authors report no conflicts
of interest. The authors alone are responsible for the
content and writing of the paper.
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