34. Muser D, Santangeli P, Castro SA, et al. Risk Stratification of Patients With Apparently Idiopathic Premature Ventricular Contractions: A Multicenter International CMR Registry. https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 24/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate JACC Clin Electrophysiol 2020; 6:722. 35. Hosseini F, Thibert MJ, Gulsin GS, et al. Cardiac Magnetic Resonance in the Evaluation of Patients With Frequent Premature Ventricular Complexes. JACC Clin Electrophysiol 2022; 8:1122. 36. Pellegrino PL, Casavecchia G, Gravina M, et al. Concealed structural heart disease discovered at cardiac magnetic resonance in patients with ventricular extrasystoles from ventricular outflow tract and apparently normal hearts. J Interv Card Electrophysiol 2021; 61:45. 37. Lip GYH, Coca A, Kahan T, et al. Hypertension and cardiac arrhythmias: a consensus document from the European Heart Rhythm Association (EHRA) and ESC Council on Hypertension, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulaci n Card aca y Electrofisiolog a (SOLEACE). Europace 2017; 19:891. 38. Muser D, Tritto M, Mariani MV, et al. Diagnosis and Treatment of Idiopathic Premature Ventricular Contractions: A Stepwise Approach Based on the Site of Origin. Diagnostics (Basel) 2021; 11. 39. Ghannam M, Siontis KC, Kim MH, et al. Risk stratification in patients with frequent premature ventricular complexes in the absence of known heart disease. Heart Rhythm 2020; 17:423. 40. Tang JKK, Andrade JG, Hawkins NM, et al. Effectiveness of medical therapy for treatment of idiopathic frequent premature ventricular complexes. J Cardiovasc Electrophysiol 2021; 32:2246. 41. Zhong L, Lee YH, Huang XM, et al. Relative efficacy of catheter ablation vs antiarrhythmic drugs in treating premature ventricular contractions: a single-center retrospective study. Heart Rhythm 2014; 11:187. 42. Chandraratna PA. Comparison of acebutolol with propranolol, quinidine, and placebo: results of three multicenter arrhythmia trials. Am Heart J 1985; 109:1198. 43. Hasdemir C, Ulucan C, Yavuzgil O, et al. Tachycardia-induced cardiomyopathy in patients with idiopathic ventricular arrhythmias: the incidence, clinical and electrophysiologic characteristics, and the predictors. J Cardiovasc Electrophysiol 2011; 22:663. 44. Baman TS, Lange DC, Ilg KJ, et al. Relationship between burden of premature ventricular complexes and left ventricular function. Heart Rhythm 2010; 7:865. 45. Takemoto M, Yoshimura H, Ohba Y, et al. Radiofrequency catheter ablation of premature ventricular complexes from right ventricular outflow tract improves left ventricular dilation https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 25/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate and clinical status in patients without structural heart disease. J Am Coll Cardiol 2005; 45:1259. 46. Wijnmaalen AP, Delgado V, Schalij MJ, et al. Beneficial effects of catheter ablation on left ventricular and right ventricular function in patients with frequent premature ventricular contractions and preserved ejection fraction. Heart 2010; 96:1275. 47. Yarlagadda RK, Iwai S, Stein KM, et al. Reversal of cardiomyopathy in patients with repetitive monomorphic ventricular ectopy originating from the right ventricular outflow tract. Circulation 2005; 112:1092. 48. Yokokawa M, Good E, Crawford T, et al. Recovery from left ventricular dysfunction after ablation of frequent premature ventricular complexes. Heart Rhythm 2013; 10:172. 49. Marcus GM. Evaluation and Management of Premature Ventricular Complexes. Circulation 2020; 141:1404. 50. Lamba J, Redfearn DP, Michael KA, et al. Radiofrequency catheter ablation for the treatment of idiopathic premature ventricular contractions originating from the right ventricular outflow tract: a systematic review and meta-analysis. Pacing Clin Electrophysiol 2014; 37:73. 51. Deyell MW, Park KM, Han Y, et al. Predictors of recovery of left ventricular dysfunction after ablation of frequent ventricular premature depolarizations. Heart Rhythm 2012; 9:1465. 52. Im SI, Voskoboinik A, Lee A, et al. Predictors of long-term success after catheter ablation of premature ventricular complexes. J Cardiovasc Electrophysiol 2021; 32:2254. 53. Oomen AWGJ, Dekker LRC, Meijer A. Catheter ablation of symptomatic idiopathic ventricular arrhythmias : A five-year single-centre experience. Neth Heart J 2018; 26:210. 54. Wang JS, Shen YG, Yin RP, et al. The safety of catheter ablation for premature ventricular contractions in patients without structural heart disease. BMC Cardiovasc Disord 2018; 18:177. 55. Cojocaru C, Penela D, Berruezo A, Vatasescu R. Mechanisms, time course and predictability of premature ventricular contractions cardiomyopathy-an update on its development and resolution. Heart Fail Rev 2022; 27:1639. 56. Penela D, J uregui B, Fern ndez-Armenta J, et al. Influence of baseline QRS on the left ventricular ejection fraction recovery after frequent premature ventricular complex ablation. Europace 2020; 22:274. 57. Cairns JA, Connolly SJ, Roberts R, Gent M. Randomised trial of outcome after myocardial infarction in patients with frequent or repetitive ventricular premature depolarisations: CAMIAT. Canadian Amiodarone Myocardial Infarction Arrhythmia Trial Investigators. Lancet 1997; 349:675. https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 26/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate 58. Julian DG, Camm AJ, Frangin G, et al. Randomised trial of effect of amiodarone on mortality in patients with left-ventricular dysfunction after recent myocardial infarction: EMIAT. European Myocardial Infarct Amiodarone Trial Investigators. Lancet 1997; 349:667. 59. Singh SN, Fletcher RD, Fisher SG, et al. Amiodarone in patients with congestive heart failure and asymptomatic ventricular arrhythmia. Survival Trial of Antiarrhythmic Therapy in Congestive Heart Failure. N Engl J Med 1995; 333:77. 60. Murray GL. Ranolazine is an Effective and Safe Treatment of Adults with Symptomatic Premature Ventricular Contractions due to Triggered Ectopy. Int J Angiol 2016; 25:247. 61. Yeung E, Krantz MJ, Schuller JL, et al. Ranolazine for the suppression of ventricular arrhythmia: a case series. Ann Noninvasive Electrocardiol 2014; 19:345. 62. Nanda S, Levin V, Martinez MW, Freudenberger R. Ranolazine treatment of ventricular tachycardia and symptomatic ventricular premature beats in ischemic cardiomyopathy. Pacing Clin Electrophysiol 2010; 33:e119. 63. Murdock DK, Kaliebe JW. Suppression of frequent ventricular ectopy in a patient with hypertrophic heart disease with ranolazine: a case report. Indian Pacing Electrophysiol J 2011; 11:84. 64. Scirica BM, Morrow DA, Hod H, et al. Effect of ranolazine, an antianginal agent with novel electrophysiological properties, on the incidence of arrhythmias in patients with non ST- segment elevation acute coronary syndrome: results from the Metabolic Efficiency With Ranolazine for Less Ischemia in Non ST-Elevation Acute Coronary Syndrome Thrombolysis in Myocardial Infarction 36 (MERLIN-TIMI 36) randomized controlled trial. Circulation 2007; 116:1647. 65. Polytarchou K, Manolis AS. Ranolazine and its Antiarrhythmic Actions. Cardiovasc Hematol Agents Med Chem 2015; 13:31. 66. Echt DS, Liebson PR, Mitchell LB, et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial. N Engl J Med 1991; 324:781. 67. Waldo AL, Camm AJ, deRuyter H, et al. Effect of d-sotalol on mortality in patients with left ventricular dysfunction after recent and remote myocardial infarction. The SWORD Investigators. Survival With Oral d-Sotalol. Lancet 1996; 348:7. 68. Hyman MC, Mustin D, Supple G, et al. Class IC antiarrhythmic drugs for suspected premature ventricular contraction-induced cardiomyopathy. Heart Rhythm 2018; 15:159. 69. Penela D, Acosta J, Aguinaga L, et al. Ablation of frequent PVC in patients meeting criteria for primary prevention ICD implant: Safety of withholding the implant. Heart Rhythm 2015; 12:2434. https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 27/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate 70. Podrid PJ, Fogel RI, Fuchs TT. Ventricular arrhythmia in congestive heart failure. Am J Cardiol 1992; 69:82G. 71. Chadda K, Goldstein S, Byington R, Curb JD. Effect of propranolol after acute myocardial infarction in patients with congestive heart failure. Circulation 1986; 73:503. 72. Lichstein E, Morganroth J, Harrist R, Hubble E. Effect of propranolol on ventricular arrhythmia. The beta-blocker heart attack trial experience. Circulation 1983; 67:I5. 73. Manolis AS. The clinical challenge of preventing sudden cardiac death immediately after acute ST-elevation myocardial infarction. Expert Rev Cardiovasc Ther 2014; 12:1427. 74. Hayes DL, Boehmer JP, Day JD, et al. Cardiac resynchronization therapy and the relationship of percent biventricular pacing to symptoms and survival. Heart Rhythm 2011; 8:1469. 75. Lakkireddy D, Di Biase L, Ryschon K, et al. Radiofrequency ablation of premature ventricular ectopy improves the efficacy of cardiac resynchronization therapy in nonresponders. J Am Coll Cardiol 2012; 60:1531. 76. Yokokawa M, Kim HM, Good E, et al. Relation of symptoms and symptom duration to premature ventricular complex-induced cardiomyopathy. Heart Rhythm 2012; 9:92. 77. Lee AKY, Andrade J, Hawkins NM, et al. Outcomes of untreated frequent premature ventricular complexes with normal left ventricular function. Heart 2019; 105:1408. 78. Latchamsetty R, Bogun F. Premature Ventricular Complex-Induced Cardiomyopathy. JACC Clin Electrophysiol 2019; 5:537. 79. Podrid PJ, Lampert S, Graboys TB, et al. Aggravation of arrhythmia by antiarrhythmic drugs incidence and predictors. Am J Cardiol 1987; 59:38E. 80. Madias C, Estes NAM 3rd. Class IC antiarrhythmic agents in structural heart disease: Is nothing CAST in stone? Heart Rhythm 2018; 15:164. 81. Lee V, Hemingway H, Harb R, et al. The prognostic significance of premature ventricular complexes in adults without clinically apparent heart disease: a meta-analysis and systematic review. Heart 2012; 98:1290. 82. Lin CY, Chang SL, Lin YJ, et al. An observational study on the effect of premature ventricular complex burden on long-term outcome. Medicine (Baltimore) 2017; 96:e5476. 83. Agarwal SK, Heiss G, Rautaharju PM, et al. Premature ventricular complexes and the risk of incident stroke: the Atherosclerosis Risk In Communities (ARIC) Study. Stroke 2010; 41:588. 84. Agarwal SK, Chao J, Peace F, et al. Premature ventricular complexes on screening electrocardiogram and risk of ischemic stroke. Stroke 2015; 46:1365. 85. Boas R, Thune JJ, Pehrson S, et al. Prevalence and prognostic association of ventricular arrhythmia in non-ischaemic heart failure patients: results from the DANISH trial. Europace https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 28/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate 2021; 23:587. 86. Ruwald AC, Aktas MK, Ruwald MH, et al. Postimplantation ventricular ectopic burden and clinical outcomes in cardiac resynchronization therapy-defibrillator patients: a MADIT-CRT substudy. Ann Noninvasive Electrocardiol 2018; 23:e12491. 87. Bhonsale A, James CA, Tichnell C, et al. Incidence and predictors of implantable cardioverter-defibrillator therapy in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy undergoing implantable cardioverter-defibrillator implantation for primary prevention. J Am Coll Cardiol 2011; 58:1485. 88. Manolis TA, Manolis AA, Apostolopoulos EJ, et al. Cardiac arrhythmias in pregnant women: need for mother and offspring protection. Curr Med Res Opin 2020; 36:1225. 89. Cox JL, Gardner MJ. Treatment of cardiac arrhythmias during pregnancy. Prog Cardiovasc Dis 1993; 36:137. 90. Newcombe PF, Renton KW, Rautaharju PM, et al. High-dose caffeine and cardiac rate and rhythm in normal subjects. Chest 1988; 94:90. 91. Myers MG. Caffeine and cardiac arrhythmias. Ann Intern Med 1991; 114:147. 92. Newby DE, Neilson JM, Jarvie DR, Boon NA. Caffeine restriction has no role in the management of patients with symptomatic idiopathic ventricular premature beats. Heart 1996; 76:355. 93. Tong C, Kiess M, Deyell MW, et al. Impact of frequent premature ventricular contractions on pregnancy outcomes. Heart 2018; 104:1370. Topic 122361 Version 25.0 https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 29/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate GRAPHICS 12-lead electrocardiogram of epicardial premature ventricular complex Courtesy of Antonis Manolis, MD. Graphic 139336 Version 1.0 https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 30/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate Single lead electrocardiogram (ECG) showing an interpolated ventricular premature beat (VPB) The third beat is a ventricular premature beat (VPB). It is called an interpolated VPB since it does not alter the underlying sinus RR interval. Graphic 72768 Version 3.0 Sinus rhythm The normal P wave in sinus rhythm is slightly notched since activation of the right atrium precedes that of the left atrium. The P wave is upright in a positive direction in leads I and II. A P wave with a uniform morphology precedes each QRS complex. The rate is between 60 and 100 beats per minute and the cycle length is uniform between sequential P waves and QRS complexes. In addition, the P wave morphology and PR intervals are identical from beat to beat. Graphic 69872 Version 2.0 https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 31/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate Polymorphic premature ventricular complexes Courtesy of Antonis Manolis, MD. Graphic 139350 Version 1.0 https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 32/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate Left ventricular outflow tract premature ventricular complexes Courtesy of Antonis Manolis, MD. Graphic 139343 Version 1.0 https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 33/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate Right ventricular outflow tract premature ventricular complexes Courtesy of Antonis Manolis, MD. Graphic 139349 Version 1.0 https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 34/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate Triggers for premature ventricular contractions Trigger Patient group Test Alcohol Patients reporting alcohol use, Alcohol screen, urine toxicology physical examination signs of alcohol use Caffeine (eg, coffee or tea Patients reporting caffeine use intake) Recreational/stimulating drugs Patients in whom stimulant drug use is suspected Drug screen (eg, for cocaine, amphetamines) Electrolyte abnormalities (eg, potassium or magnesium) Patients with suspected metabolic derangements (eg, vomiting, diarrhea, diuretic use, Serum electrolytes etc) Hypoxia Patients with COPD or other Pulse oximetry, arterial blood chronic lung disease gas Uncontrolled hypertension Patients with a history of hypertension or risk factors for hypertension Blood pressure measurement Hyper/hypothyroidism Patients with symptoms/signs of hyper- or hypothyroidism TSH High digoxin level Patients taking the drug Digoxin level Heart failure exacerbation Patients with heart failure symptoms or physical examination signs of volume overload Brain-type natriuretic peptide Anemia Patients with symptoms/signs of anemia Complete blood count Psychological stress/anxiety Patients reporting increase in life stressors, anxiety Menopausal transition Females in the perimenopause period COPD: chronic obstructive pulmonary disease; TSH: thyroid-stimulating hormone. Graphic 138370 Version 1.0 https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 35/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate Approach to premature ventricular complex treatment in high-risk patients This algorithm is for high-risk patients with PVCs. The treatment approach and algorithm for low-risk patients with PVCs are presented separately. Refer to UpToDate content for further details. PVC: premature ventricular complex/contraction; BB: beta blockers; HF: heart failure. Refer to UpToDate content for further detail. Mitigating triggers: curtail or eliminate alcohol, coffee, or tea intake; abstain from recreational/stimulating drugs; and correct electrolyte abnormalities, hypoxia, hyperadrenergic state, and uncontrolled hypertension. Refer to UpToDate content for further detail. Sometimes, a patient will prefer to stop the beta blocker after symptom relief is achieved. In this case, one can try to wean the beta blocker after 6 to 12 months of medication treatment. The dose can be gradually reduced, and a 24-hour Holter recording can be repeated periodically. It is preferable to keep the patient on at least a https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 36/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate low dose of beta blocker if they are willing, as this may prevent PVC reoccurrence. Graphic 138294 Version 1.0 https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 37/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate Oral beta blockers and calcium channel blockers for management of premature ventricular complexes in high-risk or symptomatic adult patients Other Medication name Initial dose Maximum dose considerations Beta blockers Metoprolol IR 25 mg twice daily 400 mg daily in 2 or 3 Commonly used divided doses (doses higher than 100 mg twice daily are rarely used) Metoprolol succinate ER 50 mg once daily 400 mg daily (doses higher than 200 mg May be used in patients with HFrEF at once daily are rarely used) lower initial dose of 12.5 to 25 mg once daily Carvedilol IR 3.125 mg twice daily 25 mg twice daily Commonly used; may be used in patients with HFrEF Bisoprolol 2.5 mg once daily 10 mg once daily Nebivolol 5 mg once daily 40 mg once daily Lower doses of 1.25 to 10 mg to be used in patients with HF Atenolol 25 mg once daily 200 mg once daily (doses higher than 100 Avoid in patients with HF mg once daily are rarely used) Nadolol 40 mg once daily 120 mg daily Avoid in patients with HF; first-choice therapy in some channelopathies Betaxolol 5 mg once daily 20 mg once daily Avoid in patients with HF Propranolol IR 10 mg two or three times daily 80 mg daily twice daily Avoid in patients with HF; first-choice therapy in some channelopathies and in hyperthyroidism Propranolol LA 80 mg once daily 160 mg once daily Avoid in patients with HF; first-choice therapy https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 38/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate in some channelopathies and in hyperthyroidism Calcium channel blockers* Diltiazem (12-hour) 60 mg twice daily 180 mg twice daily Diltiazem ER (24- 120 mg once daily 360 mg once daily hour) Verapamil IR 40 or 80 mg three times daily 120 mg three times daily Verapamil ER 120 or 180 mg once daily 360 mg once daily or 180 mg twice daily Initial and usual maximal dosages for reduction of PVC burden. Initial dose may be titrated (eg, at two-week intervals) as necessary for reduction in symptoms that correspond with a reduction in PVCs; refer to UpToDate topic review of PVC treatment and prognosis for additional information, including patient selection and monitoring. IR: immediate release; ER: extended release; LA: long acting; HFrEF: heart failure with reduced ejection fraction; PVC: premature ventricular complex. In patients without reduced left ventricular ejection fraction or structural heart disease, a non- dihydropyridine calcium channel blocker can be substituted if beta blockers are not tolerated or are not successful in reducing symptoms. Patients with a cardiomyopathy, with or without HF symptoms, should not be treated with calcium channel blocker. Graphic 138406 Version 2.0 https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 39/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate Approach to treatment in patients with premature ventricular complexes (PVCs ACE: angiotensin converting enzyme inhibitor; ARB: angiotensin receptor blocker; BB: beta blockers; CCB: cal hypertension; PVC: premature ventricular complex/contraction. It is important to evaluate for potential PVC triggers as simple lifestyle changes may prove effective (eg, cur recreational/stimulating drugs). Other triggers to be considered include electrolyte abnormalities, hypoxia, h The evaluation for structural heart disease and primary electrical disease typically includes close scrutiny o exercise stress testing and/or cardiac magnetic resonance imaging. If monotherapy with BB or CCB results in minimal or no change in symptoms, stop the initial agent and con Patients with a cardiomyopathy, with or without HF symptoms, should not be treated with CCB. Patients w reduction in PVC burden and improvement in left ventricular ejection fraction) should be referred for cathete For patients with ongoing PVC-related symptoms following initial medical therapy, or for those who do not ablation, rather than antiarrhythmic drug therapy, as the next treatment. However, for patients without struc antiarrhythmic drug approach is a reasonable next choice, although the long-term efficacy of catheter ablati Refer to UpToDate content on HF with reduced ejection fraction for additional details of standard HF therap Examples of underlying heart disease include CAD, hypertrophic cardiomyopathy, arrhythmogenic right ve disorder of interest for additional treatment details. https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 40/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate Graphic 126128 Version 1.0 https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 41/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate Effect of amiodarone in CAMIAT Effect of amiodarone versus placebo in 1202 postmyocardial infarction patients with ventricular ectopy in the CAMIAT trial. By an intention to treat analysis, amiodarone produced a significant reduction in arrhythmic death (top panel, p = 0.016) but no change in all-cause mortality (bottom panel). Data from: Cairns JA, Connolly SJ, Gent M, et al. Lancet 1997; 349:675. Graphic 67684 Version 2.0 https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 42/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate Revised (2018) Vaughan Williams classification of antiarrhythmic drugs abridged table Class 0 (HCN channel blockers) Ivabradine Class I (voltage-gated Na+ channel blockers) Class Ia (intermediate dissociation): Quinidine, ajmaline, disopyramide, procainamide Class Ib (rapid dissociation): Lidocaine, mexilitine Class Ic (slow dissociation): Propafenone, flecainide Class Id (late current): Ranolazine Class II (autonomic inhibitors and activators) Class IIa (beta blockers): Nonselective: carvedilol, propranolol, nadolol Selective: atenolol, bisoprolol, betaxolol, celiprolol, esmolol, metoprolol Class IIb (nonselective beta agonists): Isoproterenol Class IIc (muscarinic M2 receptor inhibitors): Atropine, anisodamine, hyoscine, scopolamine Class IId (muscarinic M2 receptor activators): Carbachol, pilocarpine, methacholine, digoxin Class IIe (adenosine A1 receptor activators): Adenosine Class III (K+ channel blockers and openers) Class IIIa (voltage dependent K+ channel blockers): Ambasilide, amiodarone, dronedarone, dofetilide, ibutilide, sotalol, vernakalant Class IIIb (metabolically dependent K+ channel openers): https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 43/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate Nicorandil, pinacidil Class IV (Ca++ handling modulators) Class IVa (surface membrane Ca++ channel blockers): Bepridil, diltiazem, verapamil Class IVb (intracellular Ca++ channel blockers): Flecainide, propafenone Class V (mechanosensitive channel blockers): No approved medications Class VI (gap junction channel blockers) No approved medications Class VII (upstream target modulators) Angiotensin converting enzyme inhibitors Angiotensin receptor blockers Omega-3 fatty acids Statins HCN: hyperpolarization-activated cyclic nucleotide-gated; Na: sodium; K: potassium; Ca: calcium. Graphic 120433 Version 3.0 https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 44/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate Encainide and flecainide increase cardiac mortality Results of the Cardiac Arrhythmia Suppression Trial (CAST) in patients with ventricular premature beats after myocardial infarction. Patients receiving encainide or flecainide had, when compared with those receiving placebo, a significantly lower rate of avoiding a cardiac event (death or resuscitated cardiac arrest) (left panel, p = 0.001) and a lower overall survival (right panel, p = 0.0006). The cause of death was arrhythmia or cardiac arrest. Data from Echt DS, Liebson PR, Mitchell B, et al. N Engl J Med 1991; 324:781. Graphic 59975 Version 5.0 https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 45/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate Decreased survival with sotalol in the SWORD trial Results from the Survival With Oral d-Sotalol (SWORD) trial. The administration of d-sotalol to patients with an ejection fraction 40 percent after either recent myocardial infarction (MI) or after symptomatic heart failure with a remote (>42 days) MI was associated with increased mortality compared with placebo (5 versus 3.1 percent). The excess number of deaths was presumed to be primarily due to arrhythmias. Data from: Waldo AL, Camm AJ, DeRuyter H, et al. Lancet 1996; 348:7. Graphic 71934 Version 3.0 https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 46/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate Approach to premature ventricular complex treatment in low-risk patients This algorithm is for low-risk patients with PVCs. PVC: premature ventricular complex/contraction; BB: beta blocker; CCB: calcium channel blocker. Examples of other pre-existing heart disease include coronary artery disease, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, etc. Refer to specific UpToDate content for further information. Curtailing or eliminating alcohol, coffee, or tea intake, and abstaining from recreational/stimulating drugs. Correct electrolyte abnormalities, https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 47/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate hypoxia, hyperadrenergic state, and uncontrolled hypertension. Refer to UpToDate for further information. PVC burden can be assessed with 24-hour cardiac monitoring. Refer to UpToDate for further information on cardiac monitoring, PVC burden, and symptom assessment. In a patient with lower or no symptoms and burden after treatment with BB or CCB who prefers to stop or reduce their medications, a trial of weaning and/or stopping may be done after 6-12 months. Refer to UpToDate content for further detail. Refer to UpToDate content for further detail. Graphic 138293 Version 1.0 https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 48/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate Left fascicular premature ventricular complexes Courtesy of Antonis Manolis, MD. Graphic 139331 Version 1.0 https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 49/50 7/6/23, 3:35 PM Premature ventricular complexes: Treatment and prognosis - UpToDate Contributor Disclosures Antonis S Manolis, MD No relevant financial relationship(s) with ineligible companies to disclose. Hugh Calkins, MD Grant/Research/Clinical Trial Support: Adagio Medical [Atrial fibrillation]; Boston Scientific [ARVC]; Farapulse [Atrial fibrillation]; Medtronic [Atrial fibrillation]. Consultant/Advisory Boards: Abbott [Atrial fibrillation]; Atricure [Atrial fibrillation]; Biosense Webster [Catheter ablation]; Boston Scientific [ARVC and atrial fibrillation]; Medtronic [Atrial fibrillation]; Sanofi [Atrial fibrillation]. Other Financial Interest: Atricure [Lecture honoraria]; Biosense Webster [Lecture honoraria]; Boston Scientific [Lecture honoraria]; Medtronic [Lecture honoraria]. All of the relevant financial relationships listed have been mitigated. Nisha Parikh, MD, MPH No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/premature-ventricular-complexes-treatment-and-prognosis/print 50/50