Ventricular ectopic beats

Dukes, 2015Ferguson, 2004Marcus, 2020Pedersen, 2014

Occasional ventricular ectopic beats (also known as premature ventricular complexes) occur in the general population and can be symptomatic. Many people experience ventricular ectopic beats as palpitations (particularly as a sensation of ‘missed beats’), often more so at rest than during exercise, and sometimes exacerbated by alcohol or caffeine. Reduction of caffeine or alcohol intake can lessen the ectopic activity.

Frequent or symptomatic ventricular ectopic beats can be the cause or the result of left ventricular dysfunction; for patients with frequent or symptomatic ventricular ectopic beats perform an echocardiogram to evaluate patients for underlying structural heart disease. If there is no underlying heart disease (eg normal echocardiogram), explanation and reassurance will often lead to an improvement in symptoms. A small proportion of patients can develop an ectopic-mediated cardiomyopathy. These patients usually have a burden of more than 5% ventricular ectopy seen on Holter monitoring, after specialist referral.

Specific drug treatment is not usually required; however, for a patient with significant symptoms caused by ventricular ectopic beats, beta-blocker therapy may relieve symptoms. Use:

1atenolol 25 mg orally, daily, increasing if required up to 100 mg daily atenolol atenolol atenolol

OR

1metoprolol tartrate 25 mg orally, twice daily, increasing if required up to 100 mg twice daily. metoprolol metoprolol metoprolol

Verapamil or flecainide may be a suitable alternative if beta blockers are contraindicated or not tolerated, provided the patient has no evidence of left ventricular dysfunction. Also avoid flecainide if the patient has significant coronary artery disease. For a patient with significant symptoms caused by ventricular ectopic beats, suitable regimens are:

1verapamil modified-release 180 mg orally daily, increasing if required up to 360 mg daily verapamil verapamil verapamil

OR

2flecainide 50 mg orally, twice daily, increasing if required up to 150 mg twice daily. flecainide flecainide flecainide

If an ectopic-mediated cardiomyopathy is suspected, treat with metoprolol tartrate or atenolol (as above) to improve left ventricular function, even in asymptomatic patients. These patients should also receive routine heart failure treatment; see Heart failure.

Specialist treatment options include amiodarone or catheter ablation; seek specialist cardiology advice.