Ventricular Extrasystoles

Premature ventricular contractions, Premature ventricular complexes, Ventricular premature beats, PVCs

Ventricular extrasystoles are extra heartbeats that start in the lower chambers of the heart, disrupting the regular heart rhythm. While they are extremely common and usually harmless in healthy people, understanding when they need attention is important for your health.

Table of contents

• What are ventricular extrasystoles?
• How common are they?
• What causes ventricular extrasystoles?
• What are the symptoms?
• How are they diagnosed?
• When should you be concerned?
• How are they treated?
• How can you prevent them?

What are ventricular extrasystoles?

Ventricular extrasystoles are a type of irregular heartbeat, also called an arrhythmia, which means a disruption in the normal heart rhythm. These are extra heartbeats that start in one of the heart’s lower chambers, called the ventricles^[1].

• Heart ventricles (lower chambers)
• Heart atria (upper chambers)
• Sinoatrial node

Normally, your heart beats in a regular pattern. The electrical signal that tells your heart to beat starts in a special area in the top right chamber of your heart called the sinoatrial node, also known as the SA node. This signal travels through your heart in an organized way, causing the chambers to contract and pump blood^[6].

When you have a ventricular extrasystole, the electrical signal starts from the ventricles instead of from the normal place. The word “extrasystole” comes from “extra” meaning in addition, and “systole” meaning heartbeat. As a result, the signal travels differently through your heart and causes an irregular beat. This premature beat is often followed by a pause before the normal rhythm returns, creating what many people describe as a “skipped beat” or a “thump in the chest”^[5].

How common are they?

Ventricular extrasystoles are extremely common in the general population. Studies show that more than 60% of healthy individuals experience ventricular extrasystoles during a 24-hour monitoring period^[5]. Research indicates that up to 75% of people may experience them at some point^[6].

These extra beats become more common as people get older. They can happen in anyone, regardless of whether they have heart disease or not. In fact, ventricular extrasystoles are more common in men, in African-Americans, and in individuals with underlying heart disease, high blood pressure, or imbalances in minerals like potassium or magnesium^[13].

In the absence of structural heart disease, which means when your heart is otherwise healthy, ventricular extrasystoles are usually harmless and have no clinical significance. Most people with these extra beats don’t even know they have them^[4].

What causes ventricular extrasystoles?

Ventricular extrasystoles can occur without any clear cause, especially in healthy people. However, several factors are known to trigger or increase the likelihood of experiencing these extra heartbeats^[5].

Lifestyle-related factors include excessive consumption of stimulants such as caffeine, tea, and energy drinks. Smoking, alcohol consumption, lack of sleep, stress and anxiety, and intense physical exercise in some individuals can all promote ventricular extrasystoles^[5].

Medications can also trigger these extra beats. Certain nasal decongestants, antihistamines, some medications used for mental health conditions, and drugs that stimulate the heart can cause ventricular extrasystoles^[5].

Physical and chemical factors in your body may contribute as well. Hormonal changes during pregnancy or the menstrual cycle, dehydration, and imbalances in minerals and salts in your blood, particularly low potassium or magnesium levels, can promote these irregular beats^[5].

In some cases, ventricular extrasystoles may be related to an underlying heart condition. These include coronary artery disease, which is a blockage of the heart’s arteries, after-effects of a heart attack, diseases of the heart muscle called cardiomyopathies, inflammation of the heart muscle known as myocarditis, and problems with heart valves^[5]. Several conditions or factors can trigger a premature ventricular contraction, including imbalances in minerals like potassium or magnesium, heart attack, heart failure, high adrenaline from anxiety or stress, and reduced blood flow to your heart^[6].

What are the symptoms?

Many people with ventricular extrasystoles don’t experience any symptoms at all. In fact, most people don’t feel a premature ventricular contraction^[6]. These extra beats are often discovered by chance during a routine medical examination or when an electrocardiogram is performed for another reason^[15].

When symptoms do occur, they can vary greatly from person to person. The most common symptoms include unusual feelings in the chest, such as fluttering, pounding, or jumping heartbeats. Many people describe a sensation of skipped beats or missed beats. These changes may make you more aware of your own heartbeat^[1].

Some people describe the sensation as a heart flutter or a feeling that their heart has skipped a beat. Others may feel a strong beat or a thump in their chest, particularly after the pause that follows the extra beat^[6].

If you have symptoms, they’re usually minor and may include dizziness, a feeling close to fainting, heart palpitations, or pounding sensations in the neck. If you have another heart condition, you may notice that a ventricular extrasystole causes shortness of breath. You may also notice more symptoms as you have more of these extra beats^[6].

It is important to note that the presence or absence of symptoms does not affect the outlook or prognosis by itself. Patients with asymptomatic ventricular extrasystoles may potentially face the same risk for complications as those with symptoms^[4].

How are they diagnosed?

To diagnose ventricular extrasystoles, a healthcare professional will examine you and ask questions about your medical history and lifestyle habits. The health professional will listen to your heart with a tool called a stethoscope. During the physical examination, simultaneous checking of your pulse at the wrist during heart listening may reveal a diminished or absent pulse during the extra beat and a more pronounced pulse following the pause after the premature beat^[13].

Several tests are done to diagnose ventricular extrasystoles and learn their cause:

An electrocardiogram, abbreviated as ECG or EKG, is a simple test that shows how the heart is beating. It can diagnose ventricular extrasystoles. Sticky patches with sensors are placed on the chest and sometimes the arms and legs. Wires connect the sensors to a computer, which displays or prints the results. However, a routine electrocardiogram may not show any irregular beats, especially if the extra beats are infrequent^[9].

If you don’t have ventricular extrasystoles very often, a regular ECG may not find them. In such cases, your healthcare team may ask you to wear a Holter monitor, which is a small, wearable ECG device that records the heartbeat. You may need to wear this device for a day or more during your daily activities. Some personal devices, such as smartwatches, now offer portable ECG monitoring^[9].

An event monitor is another type of portable ECG device. You wear it for up to 30 days or until you have an irregular heartbeat or symptoms. You usually press a button when symptoms happen. Some event monitors automatically detect irregular heartbeats and start recording^[9].

An exercise stress test often involves walking on a treadmill or riding a stationary bike while the heart’s activity is watched. This test can show whether exercise triggers ventricular extrasystoles^[9].

Additional tests may be needed to check for underlying heart disease. These can include imaging tests to look at the structure of your heart and assess its function. The goals of the diagnostic evaluation should be to exclude or identify underlying heart disease and to assess the risk for future complications^[4].

When should you be concerned?

If you don’t have heart disease, ventricular extrasystoles may not be a concern. In the absence of significant structural heart disease, meaning when your heart is healthy with normal function and no coronary or valve disease, and when the extra beats cause no symptoms, no treatment is required^[11].

The most important factor that affects outlook is whether you have underlying heart disease. The presence of underlying heart disease remains the most powerful negative factor that affects prognosis^[4]. In normal hearts, ventricular extrasystoles are usually associated with no clinical significance. However, there are occasions where the presence of these extra beats signals a susceptibility towards more serious irregular heart rhythms, especially when heart disease is present^[15].

You should seek medical attention if you feel changes in your heartbeat. Make an appointment for a health checkup so a healthcare professional can figure out if your symptoms are due to a heart condition or another health concern^[1].

Very frequent ventricular extrasystoles can, in rare cases, lead to reduced heart function if they represent a significant burden. Generally, this means more than 10,000 extra beats per 24 hours^[5]. When ventricular extrasystoles repeatedly happen for months or years, they can cause a type of heart muscle weakening called cardiomyopathy^[6].

Ventricular extrasystoles are not always a problem. But if they repeatedly happen for months or years, they can cause heart muscle weakening. Fortunately, these extra beats usually go away with medication or other minimally invasive treatments^[6].

How are they treated?

Most people with ventricular extrasystoles don’t have heart disease and won’t need treatment^[9]. In an otherwise healthy person, no treatment is needed other than decreasing stress and avoiding caffeine, alcohol, and over-the-counter cold or hay fever remedies containing medications that stimulate the heart^[7].

The approach to ventricular extrasystoles depends on several factors: the frequency of extra beats, whether they cause bothersome symptoms, the presence or absence of underlying structural heart disease, and the estimated risk of sudden cardiac death^[11].

Treatment for symptomatic patients without cardiac disease may be managed by identifying and correcting reversible causes. This includes patient education and reassurance, avoidance of aggravating factors such as stress and caffeine-containing products, and consideration of medications if education and avoidance of triggers are not effective^[11].

When treatment is needed, beta-blockers, which are medications that slow down the heart rate, and certain calcium channel blockers such as verapamil or diltiazem can be used to treat symptomatic patients. Beta-blockers with a special property called intrinsic sympathomimetic activity may be particularly helpful^[11].

Medications are rarely used because the risk of side effects is usually greater than the benefit. The exception is people who recently had a heart attack or who have heart failure that causes symptoms. In such people, survival is improved if they are treated with beta-blockers^[7].

In patients without structural heart disease who have symptoms that persist despite using beta-blockers or calcium channel blockers, cautious use of antiarrhythmic drugs may be the next step. Class IC drugs, which include flecainide and propafenone, are effective in such patients without structural heart disease or coronary heart disease^[11].

For patients with very frequent or bothersome ventricular extrasystoles that don’t respond to medications, a procedure called catheter ablation may be considered. This is a minimally invasive treatment where a thin tube is inserted into the heart to destroy the small area of heart tissue that is causing the extra beats. Although treatment with antiarrhythmic drugs or catheter ablation is typically guided by symptoms, it may also be considered in certain patients without symptoms to reduce the burden of extra beats^[4].

How can you prevent them?

It is crucial to find out what may be causing ventricular extrasystoles and take steps ahead of time to prevent them. First of all, you should avoid stimulating substances, such as coffee, smoking, or drinking alcohol^[5].

At the same time, you should work on improving your stress management and being physically fit. It has been demonstrated that exercise can help significantly in reducing the frequency of ventricular extrasystoles. You should not neglect your diet either: remember to eat a light and healthy diet^[5].

Addressing underlying triggers like imbalances in minerals and salts in your blood, and minimizing use of stimulants can also help manage ventricular extrasystoles^[8].

Appropriate lifestyle changes can make a significant difference. Decreasing stress and avoiding caffeine, alcohol, and over-the-counter cold or hay fever remedies containing medications that stimulate the heart are important steps you can take^[7].