When To Treat Extrasystole - Dr. Rerdin

When To Treat Ventricle
Extrasystole ?
Rerdin Julario
Putri Rachmawati Dewi
Departement Cardiology and Vascular Medicine

Soetomo General Hospital Surabaya
Saturday, May 5, 18
Background
Early depolarizations of the myocardium originating in
the ventricle.
Prevalence:
• 1-4 % detected by
ECG
• 40-75% detected by
24-48 hour Holter
monitoring.
Ahn MS Journal of Lifestyle Medicine
2013; 3:1
Ng GA Heart 2006; 92: 1707-1712
Saturday, May 5, 18
Benign or malignant?
PVC
Ng GA Heart 2006; 92.

Jadhav A et al The American Journal of
the Medical Sciences 2012; 343:2
Saturday, May 5, 18
PVC
With structural heart No structural heart

disease disease

Saturday, May 5, 18
PVC

disease disease
Increased risk of
malignant
arrhythmias and
death

Saturday, May 5, 18
PVC

disease disease
Increased risk of Kennedy : associated

malignant with a benign
arrhythmias and prognosis
death

Saturday, May 5, 18
PVC

disease disease

death
MRFIT : high risk for sudden death over a 7.5
year follow up.
Framingham Heart Study : twofold increase in
the risk of all cause mortality, myocardial
Ng GA Heart 2006; 92. infarction and cardiac death.
Saturday, May 5, 18
PVC

disease disease
When we treat ?
death
year follow up.
Saturday, May 5, 18
PVC

disease disease
When we treat ?
Need further
death investigation
year follow up.
Saturday, May 5, 18
Definition
Source : www.lifeinthefastlane.com
PVCs have the following features:

• Broad QRS complex (≥ 120 ms) with abnormal
morphology.
• Premature
• Discordant ST segment and T wave changes.
• Usually followed by a full compensatory pause.
• Retrograde capture of the atria may or may not occur.
Frequent PVC àmore than 5 PVCs per minute on the routine ECG,
or more than 10-‐30 per hour during ambulatory monitoring (> 10 %)
Eugenio PL Cardiology in Review 2015;23.
Rho RW, Page RL Hurst's The Heart One 13 ed 2011.
Olgin JE, Zipes DP Braunwald's Heart Disease : A Textbook of Cardiovascular Medicine10 ed 2015
Saturday, May 5, 18
Frequency, Pattern and Complexes of PVC’s
Saturday, May 5, 18
...Frequency, Pattern and Complexes of PVC’s
Saturday, May 5, 18
Mechanism
Sinus node Early depolarization of the ectopic
focus
Right atrium Left
atrium
AV node
Left ventricle
Right ventricle
Rho RW, Page RL Hurst's The Heart One. 13

ed. 2011
Noheria A et al MDCVJ. 2015;XI(2)
Saturday, May 5, 18
Mechanism
focus
Right atrium Left
atrium Ectopic firing of a focus within the
AV node ventricles bypasses the His-Purkinje
system.
Left ventricle
Right ventricle

ed. 2011
Saturday, May 5, 18
Mechanism
focus
Right atrium Left
system.
Left ventricle
Right ventricle Depolarizes the ventricles directly.

ed. 2011
Saturday, May 5, 18
Mechanism
focus
Right atrium Left
system.
Left ventricle
Asynchronous activation of
the two ventricles.

ed. 2011
Saturday, May 5, 18
Mechanism
focus
Right atrium Left
system.
Left ventricle
Asynchronous activation of
the two ventricles.
QRS complexes with prolonged

duration and abnormal morphology.

ed. 2011
Saturday, May 5, 18
Mechanism
focus
Right atrium Left
system.
Left ventricle
Triggered mechanism : Asynchronous activation of

the two ventricles.
• Delayed
afterdepolarizations
• Early QRS complexes with prolonged
afterdepolarizations duration and abnormal morphology.
• Reentry
ed. 2011
Saturday, May 5, 18
Idiopathic PVC
• Arrhythmia not related
with any detectable RVOT LVOT
structural cardiac disease.
• 20% of all patients
referred for evaluation of
ventricular arrhythmias.
• Considered benign,
though they have been
associated with a more
than two-fold higher risk of
cardiovascular outcomes.
• Can becoming
lifethreatening arrythmias
as well
Pachon et al Journal of Atrial Fibrillation 2016; 8:6

Luebbert et al Card Electrophysiol Clin 2016; 8
Betensky et al Journal of the American College of Cardiology 2011; 57;22
Saturday, May 5, 18
Idiopathic PVC
• Arrhythmia not related
with any detectable RVOT LVOT
structural cardiac disease.
• 20% of all patients
referred for evaluation of
ventricular arrhythmias.
• Considered benign,
though they have been
associated with a more
than two-fold higher risk of
cardiovascular outcomes.
• Can becoming Common PVC ORIGIN :
lifethreatening arrythmias • RV outflow tract (80%)
as well • LV outflow tract
• Aortic cusp (10-15%)
Pachon et al Journal of Atrial Fibrillation 2016; 8:6

Luebbert et al Card Electrophysiol Clin 2016; 8
Saturday, May 5, 18
Focus locatization : General Principle
1. PVC Morfology : RBBB or LBBB?

- RBBB à from left ventricle
- LBBB à from right ventricle
2. PVC Axis : inferior or superior
- Inferior (positive lead in II, III, aVF) à from
superior wall (ex : outflow tract)
- Superior (negative lead in II, III, aVF) à from
inferior wall (ex : apex)
Yuniadi et al Kapita Selekta Aritmia 2017
Source : akademir et alcleveland clinic journal of medicine2016
Saturday, May 5, 18
R wave in lead V1
1. Anterior RVOT : a typical LBBB morphology in

lead V1.
2,3. Between the anterior RCC of the aortic valve
and the posterior RVOT : a small but variable R
wave is seen.
Source : www.jafib.com
4. Region of the LCC/aortic mitral continuity/
NCC : a distinct R wave in V1.
5. The posterior mitral annulus : RBBB
# morphology.
Asirvatham SJ. J Cardiovasc Electrophysiol. 2009;20:955

Source : www.houstonmethodist.org
Saturday, May 5, 18
Which outflow tract PVC
Betensky Score
ECG characteristic for
outflowtract PVC Lead V3 PVC
R/S transition
Measuring R/S transition in
precordial lead (Betensky score)
àfocus from RVOT/LVOT PVC R/S transition
later than SR?
Focus from anterior or posterior Yes No
RVOT :
# - Positive lead 1 : posterior Measure V2
RVOT Transition Ratio
# - Negative lead 1 : anterior
< 0.6 ≥ 0.6
From epicardial or endocardial #origin
à by MDI score
RVOT LVOT
Yuniadi et al Kapita Selekta Aritmia 2017

Saturday, May 5, 18
Differentiate RVOT and LVOT
Saturday, May 5, 18
Measuring Transition
Ratio Betensky Score
Transition Ratio:
< 0.6 = RVOT
> 0,6 = LVOT
Saturday, May 5, 18
Triggered Factor
1. Hypertension and hypertrophy
• MRFIT : The level of systolic blood pressure was linked with
the prevalence of PVCs.
• ARIC study : frequent or complex VESs are also associated
with hypertension.
Perez-Silva et al E-Journal of the ESC Council for Cardiology Practice. 2011;9:17

Jadhav A et al The American Journal of the Medical Sciences. 2012;343:2
Saturday, May 5, 18
Triggered Factor
1. Hypertension and hypertrophy
• MRFIT : The level of systolic blood pressure was linked with
the prevalence of PVCs.
• ARIC study : frequent or complex VESs are also associated
with hypertension.
2. Caffeine
• Dobmeyer et al : Caffeine did not affect cardiac conduction
but did alter some of the electrophysiologic measurements.
• Graboys et al : No changes of arrhytmias were seen with a
modest dose of 200 mg of caffeine.
• DeBacker et al : caffeine restriction does not appear to have
any significant effect on PVC frequency.

Saturday, May 5, 18
...Triggered Factor
3. Exercise
• Jouven et al : Demonstrate an association between the
occurrence of frequent VES during exercise and a long-term
increase in cardiovascular death.
• Frolkis et al : Frequent VESs after exercise were a better
predictor of increased risk of death than VESs occurring only
during exercise.

Saturday, May 5, 18
...Triggered Factor
3. Exercise
• Jouven et al : Demonstrate an association between the
occurrence of frequent VES during exercise and a long-term
increase in cardiovascular death.
• Frolkis et al : Frequent VESs after exercise were a better
predictor of increased risk of death than VESs occurring only
during exercise.
4. RVOT Tachycardia
• Caused by cyclic AMP (adenosine monophosphate) mediated
triggered activity.
• Long-term prognosis in patients with truly idiopathic RVOT-VT is
excellent despite frequent episodes of VT

Saturday, May 5, 18
Clinical Diagnose
Sign : ‘Missing a beat’ or ‘Feeling the heart has stopped’
What to concern ?
• The presence, duration and frequency of any fast palpation.
• Triggering factors.
• Ischemic and structural heart disease should be assessed for.
• Family history of sudden cardiac death.
• Presyncope or syncope related with palpitation.
Akademir B et al Cleveland Clinic Journal of Medicine. 2016;83:7
Saturday, May 5, 18
Clinical Diagnose
Sign : ‘Missing a beat’ or ‘Feeling the heart has stopped’
What to concern ?
• The presence, duration and frequency of any fast palpation.
• Triggering factors.
• Ischemic and structural heart disease should be assessed for.
• Family history of sudden cardiac death.
• Presyncope or syncope related with palpitation.
Physical examination
focus on any signs of underlying heart disease :
• Significant murmurs
• Abnormal S3 or S4
• Displaced and diffuse point of maximal
impulse
• Signs of right or left heart failure
Saturday, May 5, 18
Diagnostic tool
1. Electrocardiogram (ECG)
• Look for any evidence of underlying structural heart

disease, ex : Pathologic Q waves, Long QT interval, ST
segmen elevation, Epsilon waves, electrolyte imbalance,
etc.
• In idiopatic PVC, examination of the morphology of the PVC

on 12-lead ECG is extremely helpful.

Priori SG et al European Heart Journal. 2015
Saturday, May 5, 18
2. Holter monitoring.
• If the patient reports several episodes per

day, a 24- or 48-hour Holter monitor should
both allow for a diagnosis and document the
PVC burden.
• Useful in determining whether the PVCs are

unifocal or multifocal and whether the
patient has nonsustained or sustained VT.

Saturday, May 5, 18
3. Exercise Stress Test (EST)
• Recommended for patients with
symptoms associated with
exercise.
• PVCs that reduce in frequency

on exercise is benign
• PVC that worsen with exercise

4. Echocardiography do further investigation.

Pedersen CT et al Journal of Arrhythmia and Heart Rhythm. 2014;11:10
Saturday, May 5, 18
3. Exercise Stress Test (EST)
• Recommended for patients with
symptoms associated with
exercise.
• PVCs that reduce in frequency

on exercise is benign
• PVC that worsen with exercise

4. Echocardiography do further investigation.
• Recommended for patients with symptomatic

PVCs, a frequent of PVCs (10% burden), or
when the presence of SHD is suspected.

Saturday, May 5, 18
5. Imaging.

Saturday, May 5, 18
5. Imaging.
6. Electrophysiological study (EPS)

• The utility of EPS to determine prognosis and to guide
therapy in patients with cardiomyopathies and inherited
primary arrhythmia syndromes.
• Has been used to document the inducibility of VT, guide
ablation, assess the risks of recurrent VT or SCD, evaluate
loss of consciousness related to arrhythmia, and asses the
indications for ICD therapy.

Saturday, May 5, 18
Management
Saturday, May 5, 18
Algorithm PVCs in Primary Care
Saturday, May 5, 18
Pharmacologic Therapy
1. Beta blocker
• First-line strategy
• Reduce intracellular cyclic adenosine monophosphate and thus

reduce automaticity.
• If intolerant to side effects of β-blockade, a calcium channel

blocker may be considered Nondihydropyidine calcium channel
blockers (verapamil or diltiazem)
Saturday, May 5, 18
2. Antiarrythmic drugs
• For patients with persistent symptoms despite calcium
channel or β-blockade.
• In patients without structural heart disease a 1C agent

(flecainide or propafenone) is well tolerated.
• Sotalol has been shown to reduce the PVC burden with a

range of 8% to 67%
• Amiodarone is effective at reducing the frequency of PVCs

in patients with congestive heart failure.
Saturday, May 5, 18
Ablation

Luebbert J et al Card Electrophysiol Clin. 2016;8
Saturday, May 5, 18
Ablation
High PVC burden : pharmacotherapy or catheter ablation ?

Saturday, May 5, 18
Ablation
High PVC burden : pharmacotherapy or catheter ablation ?

Saturday, May 5, 18
Malignant PVC
• Large PVC Burden and LV Dysfunction assosiated
increased SCD
• Short Coupling Interval ( < 300 ms ) prior PVC
• Normal structural heart disease PVCs can cause Malignant

usually from His-Purkinje system, Outflow Tract , right
ventricular anterior wall, or LV papillary muscles
• Progressive PVCs are induced with exercise or stress
Ng GA Heart. 2006;92
Jadhav A et al The American Journal of the Medical Sciences. 2012;343(2)
Saturday, May 5, 18
PVC Induced Cardiomiopathy
Hemodynamic
Alterations in intracellular impairment Alterations in heart
calcium and membrane rate dynamics
ionic currents
PVC-induced
cardiomyopathy Myocardioal and
Tachycardia-induced
peripheral vascular
cardiomyopathy
autonomic dysregulation
Ventricular Increased oxygen

dyssynchrony consumption
Cha YM et al Circ Arrhythm Electrophysiol 2011; 5
Saturday, May 5, 18
Summary
• The focus of the initial evaluation of PVC is to determine whether
there is underlying structural heart disease.
• Idiopathic PVCs (in which there is no structural heart disease) have

a benign prognosis.
• Patients with structurally normal hearts and frequent PVCs should

be offered complete work-up
• Frequent PVC or high PVC burden can induced cardiomiopathy
• β-blockers may be used to control the symptoms
• Catheter ablation may be reasonable treatment in patients with PVC

high burden.
Saturday, May 5, 18
Saturday, May 5, 18
Saturday, May 5, 18
Risk factors for PVCs induced cardiomyopathy :
1. High PVC burden no clear-cut points that mark the frequency at

which cardiomyopathy is unavoidable.
2. PVC origin, morphology and duration
• PVC originating in the right ventricle can cause more severe LV

dyssynchrony.
• Longer PVC QRS duration was also associated with the presence
of cardiomyopathy.
Eugenio PL Cardiology in Review. 2015;23

Ahn MS Journal of Lifestyle Medicine. 2013;3(1)
Saturday, May 5, 18
20
Saturday, May 5, 18

When To Treat Extrasystole - Dr. Rerdin

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When To Treat Ventricle

Departement Cardiology and Vascular Medicine

Ng GA Heart 2006; 92.

With structural heart No structural heart

Ng GA Heart 2006; 92.

With structural heart No structural heart

Ng GA Heart 2006; 92.

With structural heart No structural heart

Increased risk of Kennedy : associated

Ng GA Heart 2006; 92.

With structural heart No structural heart

Increased risk of Kennedy : associated

With structural heart No structural heart

With structural heart No structural heart

PVCs have the following features:

Rho RW, Page RL Hurst's The Heart One. 13

Rho RW, Page RL Hurst's The Heart One. 13

Rho RW, Page RL Hurst's The Heart One. 13

Rho RW, Page RL Hurst's The Heart One. 13

QRS complexes with prolonged

Rho RW, Page RL Hurst's The Heart One. 13

Triggered mechanism : Asynchronous activation of

Pachon et al Journal of Atrial Fibrillation 2016; 8:6

Pachon et al Journal of Atrial Fibrillation 2016; 8:6

1. PVC Morfology : RBBB or LBBB?

Source : akademir et alcleveland clinic journal of medicine2016

1. Anterior RVOT : a typical LBBB morphology in

Asirvatham SJ. J Cardiovasc Electrophysiol. 2009;20:955

Yuniadi et al Kapita Selekta Aritmia 2017

Perez-Silva et al E-Journal of the ESC Council for Cardiology Practice. 2011;9:17

Perez-Silva et al E-Journal of the ESC Council for Cardiology Practice. 2011;9:17

Perez-Silva et al E-Journal of the ESC Council for Cardiology Practice. 2011;9:17

Perez-Silva et al E-Journal of the ESC Council for Cardiology Practice. 2011;9:17

Akademir B et al Cleveland Clinic Journal of Medicine. 2016;83:7

Akademir B et al Cleveland Clinic Journal of Medicine. 2016;83:7

• Look for any evidence of underlying structural heart

• In idiopatic PVC, examination of the morphology of the PVC

Akademir B et al Cleveland Clinic Journal of Medicine. 2016;83:7

• If the patient reports several episodes per

• Useful in determining whether the PVCs are

Akademir B et al Cleveland Clinic Journal of Medicine. 2016;83:7

• PVCs that reduce in frequency

• PVC that worsen with exercise

Akademir B et al Cleveland Clinic Journal of Medicine. 2016;83:7

• PVCs that reduce in frequency

• PVC that worsen with exercise

• Recommended for patients with symptomatic

Akademir B et al Cleveland Clinic Journal of Medicine. 2016;83:7

Akademir B et al Cleveland Clinic Journal of Medicine. 2016;83:7

6. Electrophysiological study (EPS)

Akademir B et al Cleveland Clinic Journal of Medicine. 2016;83:7

Pedersen CT et al Journal of Arrhythmia and Heart Rhythm. 2014;11:10

Akademir B et al Cleveland Clinic Journal of Medicine. 2016;83:7

• Reduce intracellular cyclic adenosine monophosphate and thus

• If intolerant to side effects of β-blockade, a calcium channel

Akademir B et al Cleveland Clinic Journal of Medicine. 2016;83:7

• In patients without structural heart disease a 1C agent

• Sotalol has been shown to reduce the PVC burden with a

• Amiodarone is effective at reducing the frequency of PVCs

Noheria A et al MDCVJ. 2015;XI(2)

High PVC burden : pharmacotherapy or catheter ablation ?

Noheria A et al MDCVJ. 2015;XI(2)

High PVC burden : pharmacotherapy or catheter ablation ?