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Forum Name: Arrhythmias

Question: Do PVCs lead to v-tach?


 KatrinaS - Sat Aug 30, 2008 6:18 pm

Hello,

I'm a 25 year-old female with normal blood pressure and good cholesterol. I've had an echo, which was normal, and a 24-hour holter monitor that showed 65 PVCs and 1 PAC. Everything else about the holter was normal. I've had a normal chest x-ray, normal blood work, as well as three separate EKGs, all which were normal. Sometimes my PVCs seem to come one right after another, and this scares me because I've read about ventricular tachycardia. Can PVCs ever turn into something worse? My cardiologist says that this is unlikely, especially given all of my normal tests. I get very worried, though. I worry about sudden cardiac death from these things. Is this even possible? I don't have any other symptoms besides the anxiety these skips cause. What are the chances of getting v-tach, and does this or ventricular fibrilation occur in someone with an otherwise normal healthy heart?
 John Kenyon, CNA - Tue Sep 02, 2008 11:32 pm

User avatar Hi there -

Your question is a very common one, and understandably a concern. I hopefully can put your mind at ease about this, though. PVCs, the most common heartbeat irregularity, occurs in almost everyone at some time or another. Some people have them very frequently, others only occasionally, others sporadically. Your Holter monitor findings are very ordinary, and 65 PVCs in a 24 hour period amount to an average of less than three per hour, which is actually infrequent, although in most cases they occur in random patterns, so some could be closer together than others. What sometimes feels like multiple PVCs (which sensation you describe in your post) can be one of several innocent things: most commonly it is one PVC which, for some unknown reason, can sometimes be percieved as a "fluttering" sensation. There's little correlation between the perceived force, number, etc., of them, and the actual characteristics of a given PVC. Group beating (ventricular bigemeny, trigenemy, etc.) means every second, third, fourth, etc., beat is a PVC in a given period of time. Some people have bigemeny as their normal rhythm. Some people aren't even aware it's happening. Also, you could actually have, on occasion, more than one consecutive PVC, and as I'm sure you've found out, three or more in a row are considered, for technical purposes, a "run" of V-tach. In reality this is an arbitrary definition, and a very conservative one.

PVCs, without any other electrical or structural abnormality, are of virtually no diagnostic nor prognostic value at all. They occur in everyone in various sorts of patterns, and again, absent any structural or neurocardiological disease, they have no real meaning. They can, however, be very alarming when they occur, and can provoke a good deal of anxiety which, unforntunately, causes the release of adrenaline, which in turn makes the heart muscle more irritable, and often thus sets off yet more PVCs, sometimes making the sufferer a nervous wreck. This is truly unfortunate, because without significant left ventricular dysfunction PVCs have no meaning at all (and even with LV dysfunction they are only an indicator, not a cause, of potential trouble).

In short, your doctor is appropriately circumspect in his answer, and PVCs really are almost always best ignored -- if possible. Sometimes it can be difficult to ignore them, which is the big problem. If they are very frequent or bothersome sometimes the doctor will prescribe a beta blocker to reduce the frequency of them, which usually helps cut down on their frequency and makes them more difficult to percieve, so that is a fallback possibility if they start to really bother you. Still, they have virtually no clinical significance otherwise, and often this knowlege is sufficient to ease the mind of a given patient enough that they are no longer seen as a problem. Hopefully this will be the case with you.

I hope this is helpful to you. Please do stay in touch with us if you have any further questions or concerns.
 KatrinaS - Sun Dec 07, 2008 6:41 pm

Thank you very much for that response. It has been about four months, and I still have the PVCs. I do my best to ignore them, but it concerns me when I feel like they come back to back. I've been told this is a pattern called bigeminy. I had an echo a year ago which was normal, and I was told that I do not need another one, is this true? Also, I wore a second holter monitor about two months ago because I was concerned that the PVCs were increasing. My first holter had 65 PVCs recorded, and my second one had 135 PVCs recorded. The doctor said that this doesn't matter how many I have in a day. I've been getting over anxiety, and on my first holter my average heart rate was 92 bpm, and on my second holter my average heart rate was 78 bpm. I'd say I've improved there, but what about the PVCs? Are they really still benign no matter how many or what pattern they're in? I'm still afraid to exercise because I'm afraid of developing a dangerous abnormal rhythm. I feel them if I sit down after walking around or if I go from sitting down to moving around all of a sudden. I still worry that the PVCs will turn into something worse. Do I have any reason to still be concerned?
 John Kenyon, CNA - Mon Dec 08, 2008 12:07 pm

User avatar Hi KatrinaS -

It's very difficult for a lot of people to reconcile the benign nature of PVCs with the way they feel (or at least as they are perceived in a lot of people -- not everyone feels them, which I find strange, but only because I feel mine quite clearly). Still, they carry no diagnostic nor prognostic value at all. It was once believed that frequent PVCs were ominous in very specific settings critical clinical settings, but now it has been determined beyond any reasonable doubt that even in those specific settings (people with severe heart disease and compromised function due to damage from prior heart attack or structural disease) half of those who die because of advanced heart disease have had no PVCs during or immediately prior to the terminal event. In other words, PVCs don't cause sudden cardiac death, nor do they predict it. They are rarely treated now, even in those serious clinical settings. They are normal in the general population, and some people have them extremely frequently (sometimes thousands in 24 hours) while others have them only occasionally. The rates of occurrence evidenced by your Holter monitor recordings would rank as occasional to infrequent, but the extremely unpleasant sensation (and some are just far more sensitive to it than others) makes some feel there must be something sinister going on. It's understandable, too. The heart, when it's working in an orderly fashion, is not usually noticed. However, like our breathing, once attention has been attracted to it, it is very difficult to ignore.

The phenomenon of bigemeny (and trigemeny and quadragemeny -- I think they stopped naming after every fourth beat) is based on a physiological rule that's actually rather arcane, but the rule itself proves that even bigemeny is a benign rhythm; However, it can be, for some people, extremely uncomfortable. I've found that sometimes people will notice it and at other times not. Part of the reason for this is the timing of PVCs, and bigemeny, since it is very regular in its irregularity, follows its own rule, that when a PVC fires while the tricuspid valve is shut, it causes a much more noticebale "kick" and sometimes a very creepy sensation of backing up into the jugular in the neck, which is exactly what happens. With bigemeny if the first one happens at that point in the cycle, then the rest in that "row" will also. It makes no difference and nothing bad will happen, but those feel even more "wrong" than PVCs that occur when the tricuspid valve is open and the extra blood that collects in the half second or less of the pause before the next regular beat can be pushed out more easily, so doesn't cause the "water hammer" effect.

It's all very technical and involves both electrical and plumbing issues, but the bottom line is that your doctor is absolutely correct: they are benign, and it doesn't matter how many you have (except in a psychological sense). There are some who have bigemeny as their "normal" rhythm, and in some it goes away with exercise only to return upon cooling down. The only time PVCs are of any interest at all is when they occur in a setting of severe left ventricular dysfunction or marked structural disease (causing the same dysfunction in a different way). Either of these will have far more troubling and debilitating symptoms that PVCs, either is quite evident of cardiac workup, and even with all that said, the patient may not have any more PVCs than a randomly chosen healthy person and they still aren't usually treated, just noted.

It sounds as though you've done a lot of calming if you've gotten your average resting heart rate down from the 90s to the 70s, which speaks well for your emotional health, which is the primary concern. You're perfectly safe in resuming a fitness program, though you will likely notice PVCs when you change from an active to a resting status or sometimes vice versa. (For some they always go away with exercise and return after, and for others it works the opposite way). Avoidance of caffeine, nicotine, alcohol, sleep disturbances and stress are a few ways to possibly reduce the frequency of the palpitations, but even then there's no guarantee they won't just kick up now and again, and that's perfectly normal.

You definitely can put your concerns to rest. Following through by slowly learning to not notice or not attach any value to those occasional unpleasant sensations is another matter, and for most of us, only time and experience will really convince us they're harmless, no matter what our doctors tells us. It's hard to ignore someone who keeps tapping you on the shoulder -- or inside the chest.

I hope this helps dispel your concerns as much as is possible. It's a remarkably common concern, but people tend not to mention it to others for some reason. If they did, we'd all probably be better off. Thanks for bringing your concerns here. Best of luck to you.
 KatrinaS - Wed Jan 07, 2009 5:35 pm

Thank you very much for your responses, Dr. Kenyon. You provided such honest and detailed answers, and I really appreciate that. One other thing that I forgot to ask is in regards to the testing I've had for my PVCs. I had an echocardiagram done one year ago. I had two holter monitors done during 2008 a few months apart, as well as a few EKGs, chest xray, and blood tests. Like I said, these tests all came back normal, and the holter caught the PVCs. Have I had all of the necessary tests done? I've read many people getting stress tests, but my cardiologist and other said they didn't think that was necessary. I'm almost 26 years old, and I've read other people's postings who are around my age having stress tests. Is this something I should have? Also, is there any need to repeat any of my tests? I'm mostly referring to the echo because I had that a year ago. I noticed you mentioned in a posting that you get PVCs and feel them, too. Have you ever had yours recorded? Do you know how many a day you get? Just curious since so many people are in the same boat!
 John Kenyon, CNA - Thu Jan 08, 2009 12:57 pm

User avatar Hi again -

You're very welcome. Given your overall history the choice of stress test vs. no stress test is a "doctor's choice" situation. It's really not indicated but would do no harm, and might help ease your mind. The doctor has to weigh the value vs. expense, etc., before suggesting pro or con. It seems unlikely it would bring anything new to light, but if you would feel better for having it done and have coverage or the means to pay for one, then my all means press for it. You've had all the requisite tests done to cover the problem that brought you in, and you're basically good to go.

People who've had one echocardiogram (adults that is) and have had it come back negative (which is a positive thing -- confusing, eh?) usually aren't suggested another unless new and different symptoms arise. So the answer, at least for the time being, is that you shouldn't need another.

Due to the nature of my work I've had the opportunity to "play" with a lot of testing devices (as well as some reason to at times, as well), including various cardiac recording devices, including the Holter monitor.I don't usually do this, but I'll tell you what my most "interesting" result was: one time (perhaps I was drinking more coffee than usual) I showed up more than 5700 PVCs in 24 hours. This actually wasn't so remarkable, but I was surprised nonetheless. And of course we all made jokes about it and that was that. Seriously, the number of them can be almost zero or can be in the tens of thousands and be equally irrelevent; it mostly depends on how bothersome the sensation is to an individual and if there is any significant structural abnormality. In the absence of the latter, it really doesn't matter.

Good luck to you and please stay in touch. If you have any further questions, don't hesitate to bring them here.
 KatrinaS - Tue Mar 03, 2009 4:47 pm

You have been such a tremendous help to me in explaining everything so clearly. I do have something else I would like to ask about if that's alright. I wore one of those 30-day event monitors about a month and a half ago. It was becuase I had "complained" enough about my PVC's that my doctor wanted me to wear one in case there was something I was feeling that was different than just PVC's. I wore it continuously for a week, and then a few times the remaining time I had the monitor for because I was able to capture everything that normally concerns me during that first week of wearing it. My doctor didn't have much to say about it after all the results were in, and he said there was nothing dangerous reported, and it was usual PVC's (some short bigeminy) with normal sinus rhythm. I was able to get a copy of the summary of the strips, and there are just two things that I don't know what they mean and would like explained to me. There was one time when the monitor captured PJC's...what is a PJC? The other thing was (and I'm glad I was able to get this recorded) when I feel my heart sort of flutter for a brief second and feels different than a PVC skip. The monitor said this was five beats of AIVR. What is AIVR, and is it something I should be worried about? I'm not overly concerned since my doctor said no news is good news, and he didn't have any news for me, but I'd just like to know what those things are and if I should actually be concerned or not. Thanks again in advance for taking the time to read and answer my questions!
 John Kenyon, CNA - Thu Mar 05, 2009 12:31 am

User avatar Hello and thank you for the kind words. I'm glad I've been helpful, and I never mind additional questions. That's what we're here for!

Your questions are very interesting (and interested, too, which is good). While I usually don't mention PJCs (there are just so many types of premature beats) but since you asked, and it is your heart after all, I'll tell you: it stands for premature junctional contraction. What sets these apart from PVCs and PACs is, of course, their locus of origin, and since they originate in the atrioventricular junction (or AV node -- sometimes are called "nodal" premature beats), they don't look very exciting on the EKG and, in fact, they aren't as a rule. They're a little less common than the other kinds, and are associated with less complaints in general, but they can show up and are, like the others, perfectly normal to have.

The runs of AIVR are a really weird, very benign, but extremely odd-feeling phenomenon. It is often seen in the ICU in patients who've had a blockage cleared, but also occcurs sometimes for no particular reason. It's a very odd sensation because it does feel like a fluttering or forceful beat, but when one checks the pulse it seems pretty regular, but is usually just a little bit faster while this is going on, but not enough to be alarming. For instance, if the resting pulse is 68 and AIVR starts (usually not for a very long period, maybe 10-15 seconds) it will feel like something funny's going on, but if you check your pulse then it's usually only a little faster (maybe 80 or so). Then the sensation goes away as does the AIVR which, by the way, stands for (are you ready?) accelerated idioventricular rhythm. Just one more little trick our hearts can do to keep us guessing, but in and of itself means nothing, even in an otherwise serious clinical setting. It does look rather distinctive on EKG, however, which sometimes disturbs the inexperienced clinician. It's nothing, but it surely does feel strange.

I hope this clarifies these things for you, and don't hesitate to ask anything any time. It's good to hear from you and I'm glad you had such an uneventful, if interesting, event monitor experience. Take care and please keep in touch.

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