What is Ventricular Premature Complexes?
Ventricular premature complexes (VPCs), also known as premature ventricular contractions (PVCs), refer to extra heartbeats that start in one of the ventricles, or lower heart chambers. They’re relatively common and can happen across a range of different medical situations and diverse groups of people. They can occur in patients with or without prior heart disease. Some studies suggest that having frequent VPCs can lead to a condition where the left chamber (ventricle) of the heart becomes larger and functions less effectively. However, this condition can usually return to normal with the successful use of a procedure called catheter ablation to treat the VPCs.
The appearance and behavior of VPCs can vary greatly. It depends on where they originate in the heart, any underlying heart disease, or the use of medications to treat abnormal heart rhythms. VPCs usually start in the lower chamber of the heart which leads to a longer QRS complex – a specific part of an EKG heart reading. This happens because of a delay in the electrical signals reaching the other side of the heart. However, in some cases, the QRS complex can be less than 120 ms, indicating that both lower chambers of the heart are activated together due to the electrical signals passing through a specific heart pathway.
Doctors categorize premature ventricular contractions based on how they appear on an EKG reading. They consider factors such as the coupling interval (how closely the extra beats follow the regular beats), the width of the QRS complex (seen on the EKG), and their complexity. Through this, they can identify where the VPCs are coming from by their appearance on the EKG. For example, if VPCs originate in the left ventricle, they’re often associated with what’s known as a right bundle branch block (a type of heart block that slows down the electrical signal), and VPCs arising from the right ventricle often show a pattern called a left bundle branch block.
What Causes Ventricular Premature Complexes?
If a patient has something called ventricular premature complexes, they usually feel their heart beating abnormally, or what doctors call “palpitations.” By talking to the patient and examining them, doctors can figure out what caused these heart irregularities. There are many things that can increase the chances of these irregular heartbeats happening more often. They can be simply due to our bodies reacting to stress. But they can also be caused by certain medications, an imbalance of minerals in the body, or low oxygen levels.
Here are some specific things that can cause ventricular premature complexes:
- Illegal drugs (like alcohol, amphetamines, or cocaine)
- Certain medications like digoxin (a heart medicine), tricyclic antidepressants (a type of depression medication), medicines that mimic adrenaline, aminophylline (an asthma drug), or caffeine
- An imbalance of certain minerals in the body, like having too little potassium or magnesium, or too much calcium
- Low oxygen levels
- High carbon dioxide levels
- A sudden blockage of blood flow to the heart muscle
- Heart disorders, usually the conditions that enlarge or thicken the heart muscle
- Inflammation of the heart muscle
- A bruise-like injury of the heart muscle
- A floppy mitral valve (the valve between the left upper and lower heart chambers)
Risk Factors and Frequency for Ventricular Premature Complexes
A study was carried out on a healthy group of military personnel. The results from a 12-lead EKG test showed that approximately 0.8% of participants had ventricular premature complexes (VPCs). People under 20 years old and over 50 years old represented a smaller proportion, with a prevalence of 0.5% and 2.2% respectively.
The Framingham Heart Study shed more light on the prevalence of VPCs. In a one-hour continuous EKG test, 33% of men and 32% of women with no history of coronary artery disease were found to have VPCs. For those with coronary artery disease, the prevalence increased to 58% in men and 49% in women. It’s worth noting that these numbers can vary due to different methods and lengths of time used to monitor VPCs.
- Several factors can influence these percentages, including:
- Coronary heart disease
- African-American ethnicity
- Male gender
- Being older in age
- Having hypertension
- Faster sinus rates
- Lower serum potassium or magnesium levels
- Lower education level
Signs and Symptoms of Ventricular Premature Complexes
Ventricular premature complexes, or VPCs, often don’t show any symptoms. But sometimes people with VPCs do experience feelings of tiredness, heart palpitations, feeling light-headed or dizzy. Patients with pre-existing heart conditions may suffer from shortness of breath, chest pains and, again, heart palpitations. Sometimes, the experience of VPCs can feel like a strange throbbing in the neck. In rare instances, VPCs can lead to a drop in blood circulation, causing fainting or near-fainting, especially if the VPCs are frequent or prolonged. For people without any symptoms, VPCs may only be found during a routine physical check-up. The doctor might hear an irregular heartbeat with a stethoscope or see it on a regular office heart monitor test.
In some situations, VPCs might be the first indicator of a heart disease that hasn’t been diagnosed yet. So for everyone diagnosed with VPCs, the doctor will generally take a detailed medical history, perform a 12-lead EKG heart test and a chest X-ray. To decide whether further tests like a Holter monitor, stress test or echocardiogram are needed, the doctor will need to assess whether the VPCs are still present after the first tests and whether the patient has any sign of heart disease or complex heart rhythm problems.
Over the last 20 years, doctors have generally believed that having VPCs without having any heart disease is generally a good sign and does not indicate any serious issues, even if the VPCs occur often. Therefore, the treatment plan for VPCs usually depends on how often they occur and whether the patient is experiencing any symptoms. However, in some cases, having VPCs very often can lead to heart muscle disease, which could warrant treatment even if the patient isn’t showing signs of illness. But it isn’t clear yet how important it is to address recurrent VPCs in patients who don’t have any signs of left ventricle dysfunction.
Testing for Ventricular Premature Complexes
If your doctor suspects you’re having heart irregularities, one of the first tests they might perform is a resting EKG, or electrocardiogram. This test can detect irregularities in your heart’s electrical activity, including something called a ventricular premature complex (VPC). A VPC is essentially an extra or early heartbeat that originates from the lower chambers of your heart called ventricles. On an EKG, a VPC presents as an abnormally shaped and premature heartbeat followed by a bigger than normal electrical wave (T-wave). Most times the heartbeat following a VPC experiences a slight delay, which is called a compensatory pause.
Something interesting to note is the shape of the EKG lines during a VPC can help estimate where in the heart the irregular beat is coming from. The most common places a VPC can come from are the left and right outflow tracts which account for about two-thirds of all VPCs. However, VPCs can also originate from other places too, such as the ventricular free wall, the septum between the ventricles, the aortic cusp, just to name a few.
The pattern of the VPCs can also offer valuable information. For instance, if the VPC happens every other heartbeat, it is referred to as bigeminy. If it happens every third heartbeat, it is called trigeminy. Sometimes, multiple VPCs occur in a row which has different names based on the number of successive VPCs. “Couplet” is used when there are two in a row, “triplet” for three, and anything more than three VPCs in a row is referred to as a “run” of VPCs or ventricular tachycardia (VT) – a condition that presents as a fast heart rate starting from the lower chambers.
In addition to the EKG, holes in the plot can be filled in using a 24-hour heart monitor, like a Holter monitor. If the monitoring doesn’t reveal any abnormalities yet the symptoms suggest otherwise, other types of longer-term monitoring, such as an event or loop recorder, can be considered. Other tests like checking electrolyte balance (especially potassium and magnesium), thyroid levels, heart damage markers (troponin), and digoxin levels might also be recommended. An echo (a type of ultrasound that looks at your heart) to check for any visible abnormalities in heart might also be carried out. Further, depending on each individual’s symptoms and case, other tests might be performed such as a stress test, a specific heart scan, a coronary angiography, or a cardiac MRI.
Treatment Options for Ventricular Premature Complexes
Patients who have structural heart disease and display early, abnormal heartbeats in the lower chambers of the heart, known as ventricular premature complexes (VPCs), should receive appropriate treatment based on their specific disease condition. Treatment is important for those who have a high number of these abnormal beats or frequently experience short bouts of rapid heart rhythm. It’s especially crucial for people whose VPCs may turn into a dangerous type of irregular heartbeat called ventricular fibrillation, which requires immediate defibrillation (an electric shock to the heart to restore normal rhythm).
If treatment is required, the typical first step is to begin with a type of medication known as beta-blockers. Beta-blockers are particularly effective in those whose VPCs increase with physical activity or stress. In the case of heart diseases like heart failure or heart attacks, beta-blockers are also recommended as the first treatment.
Another type of medication, non-dihydropyridine calcium channel blockers, might be considered for those who can’t take beta-blockers. If symptoms don’t improve with either of these medications, antiarrhythmic medications like flecainide or propafenone may be used. However, these medications may cause heart rhythm problems and can increase the risk of mortality, particularly in those with existing heart artery disease. For these patients, another drug called amiodarone has proven to be effective in controlling VPCs. However, due to potential side effects, the use of amiodarone should be closely monitored, especially in patients with underlying structural heart disease or coronary disease and significant symptoms.
If the above-mentioned treatments are not suitable or if the patient doesn’t tolerate them, they may be referred to a specialist called electrophysiologist to consider an intervention called ablation. Ablation is recommended in those who develop a disease of the heart muscle (cardiomyopathy) because of a high burden of VPCs or for those whose abnormal beats are more than 10,000 or more than 10% of all heartbeats in a 24 hour monitoring.
Cardiomyopathy is more likely to occur in patients whose VPCs have a very broad irregular signal termed QRS complex, the beats come from the outside layer of the heart or in patients with VPCs occurring more than 25% of all heartbeats recorded on a device known as a Holter monitor. This type of heart disease is generally reversible after obtaining successful ablation, but rarely some amount of heart’s pumping ability defect may persist. If patients have already developed heart disease due to frequent VPCs, they should also be considered for radiofrequency ablation, a procedure that can significantly reduce abnormal beats and improve heart’s pumping function. Ablation may also be required in patients with frequent VPCs that interfere with a treatment known as cardiac resynchronization therapy.
Several cardiology societies provide guidelines on the use of ablations in patients with VPCs. As per these guidelines, catheter ablation can be a useful step for those with reduced heart’s pumping ability which is suspected to be caused by frequent VPCs, especially for those who do not respond or can’t tolerate antiarrhythmic medications. Ablation therapy is advised for patients with reduced heart’s pumping function and frequent symptoms of VPCs or nonsustained rapid heart rhythm. Finally, patients with a specific type of heart failure and a high burden of VPCs should be aggressively treated with catheter ablation if they can’t tolerate or decline antiarrhythmic therapy.
What else can Ventricular Premature Complexes be?
It can be quite difficult to distinguish Ventricular Premature Contractions (VPCs) from other heart rhythm disorders, as there are many conditions that can look very similar to VPCs. Here are some of those conditions:
- Aberrant premature atrial contractions
- Fusion beats
- Premature junctional contractions
- Idioventricular escape rhythms
- Sustained and non-sustained ventricular tachycardia
- Bigeminy, trigeminy, or quadrigeminy
- Supraventricular tachycardia
- Atrial fibrillation
- Sinus arrhythmia
What to expect with Ventricular Premature Complexes
Heart diseases are often complicated and can have different causes leading to patient death. VPCs, or Ventricular Premature Contractions, which refers to extra, abnormal heartbeats, are frequently the main cause of death in heart conditions such as coronary artery disease and dilated cardiomyopathy. According to certain studies like the MRIFT and Framingham Heart Study, having frequent VPCs is linked to a higher risk of sudden heart-related death. However, these studies have faced criticism for potentially underestimating death rates because they don’t thoroughly investigate underlying heart conditions.
Occasional VPCs do not generally affect lifespan, but if VPCs occur frequently, this can signify a potentially worrisome outlook. After a heart attack (known medically as an MI), patients who experience frequent VPCs have a higher risk of sudden cardiac death. However, it’s important to note that there are treatments that can help patients recover from the ill effects of VPCs on heart functions. These can include medication or a specialized procedure known as catheter ablation therapy.
There are certain traits or characteristics of VPCs that could be indicate a worse prognosis including:
- When there are more than 500 VPCs in a 24-hour period as measured on a Holter monitor, a device for continual heart monitoring
- VPCs that show specific patterns in the heartbeat (known as LBBB or RBBB)
- VPCs that show wide and complex heart rhythms, or what is known as a wide QRS complex
- VPCs that come very shortly after a normal heartbeat, which are known as short-coupled VPCs
- VPCs that occur during the relaxation phase of heartbeats, called the T-wave
- VPCs that take place in response to adrenaline, which is also known as adrenergic stimulation
Possible Complications When Diagnosed with Ventricular Premature Complexes
Frequent Ventricular Premature Complexes (VPCs) can cause health complications if they are not treated. These complications can include:
- Changes in left ventricle functions
- Enlarged heart due to weakening of the muscle (Dilated Cardiomyopathy)
- Fast and irregular heartbeats (Sustained Ventricular Tachycardia)
- Sudden stopping of the heart’s function (Sudden Cardiac Arrest)
Recovery from Ventricular Premature Complexes
Cardiac rehabilitation, or the process of helping a person recover from a heart problem, has both long-term and short-term goals. The long-term goals concentrate on medical check-ups, assessing the risk of heart disease, educating people about health, encouraging lifestyle changes such as regular exercise, providing counseling, and behavior therapy. These goals help control heart diseases related to Ventricular Premature Contractions (VPCs), stop or reverse left ventricle dysfunction, which is when the left part of the heart is not pumping well enough, and lower the risk of sudden heart failure.
The short-term goals, on the other hand, include managing heart-related symptoms, reducing the mental and physical effects of heart disease, improving how well a person can perform daily activities, and enhancing their ability to return to work and regain their social life.
By following this process, cardiac rehabilitation helps improve a person’s overall lifestyle, increases their awareness of their physical ability and determination, changes risk factors, helps adjust relationships, and could furthermore help their work performance.
Preventing Ventricular Premature Complexes
When patients visit their family doctors complaining of heart palpitations or skipped beats, a thorough examination is necessary. Although these symptoms could be related to various heart-related issues, it’s important to remember that they might also be caused by non-heart-related conditions such as anemia, fever, drug use, or even anxiety in healthy people.
The best way to manage harmless irregular heartbeats, also known as benign occurring VPCs, is by helping the patient make certain lifestyle changes and giving them some reassurance. It might be helpful for the patient to fill out a questionnaire to help diagnose any potential anxiety or panic disorder issues.
It’s crucial for patients to understand when they should contact their doctor if their symptoms worsen. Interacting with various members of the healthcare team can enhance their understanding of the condition and treatment. It’s also important for patients to be aware of any changes in their treatment plan, and keeping their follow-up appointments as scheduled.
If necessary, patients should receive advice and education about the advantages of lifestyle changes such as quitting smoking and losing weight. Patient education can be supported with written pamphlets or illustrations to help reinforce their understanding.