24. Agarwal V, Vittinghoff E, Whitman IR, et al. Relation Between Ventricular Premature Complexes and Incident Heart Failure. Am J Cardiol 2017; 119:1238. 25. Jeserich M, Merkely B, Olschewski M, et al. Patients with exercise-associated ventricular ectopy present evidence of myocarditis. J Cardiovasc Magn Reson 2015; 17:100. 26. Adabag AS, Casey SA, Kuskowski MA, et al. Spectrum and prognostic significance of arrhythmias on ambulatory Holter electrocardiogram in hypertrophic cardiomyopathy. J Am Coll Cardiol 2005; 45:697. 27. Almendral J, Villacastin JP, Arenal A, et al. Evidence favoring the hypothesis that ventricular arrhythmias have prognostic significance in left ventricular hypertrophy secondary to systemic hypertension. Am J Cardiol 1995; 76:60D. 28. Almeneessier AS, Alasousi N, Sharif MM, et al. Prevalence and Predictors of Arrhythmia in Patients with Obstructive Sleep Apnea. Sleep Sci 2017; 10:142. 29. Zuchinali P, Ribeiro PA, Pimentel M, et al. Effect of caffeine on ventricular arrhythmia: a systematic review and meta-analysis of experimental and clinical studies. Europace 2016; 18:257. 30. Kerola T, Dewland TA, Vittinghoff E, et al. Modifiable Predictors of Ventricular Ectopy in the Community. J Am Heart Assoc 2018; 7:e010078. https://www.uptodate.com/contents/premature-ventricular-complexes-clinical-presentation-and-diagnostic-evaluation/print 13/23 7/6/23, 3:34 PM Premature ventricular complexes: Clinical presentation and diagnostic evaluation - UpToDate 31. Sekizuka H, Miyake H. The Relationship Between Premature Ventricular Contractions and Lifestyle-Related Habits among the Japanese Working Population (FUJITSU Cardiovascular and Respiratory Observational Study-1; FACT-1). J Nippon Med Sch 2018; 85:337. 32. Enriquez A, Frankel DS. Arrhythmogenic effects of energy drinks. J Cardiovasc Electrophysiol 2017; 28:711. 33. Engstrom G, Hedblad B, Juul-Moller S, et al. Cardiac arrhythmias and stroke: increased risk in men with high frequency of atrial ectopic beats. Stroke 2001; 31:2925. 34. Manolis AA, Manolis TA, Apostolopoulos EJ, et al. The Cardiovascular Benefits of Caffeinated Beverages: Real or Surreal? "Metron Ariston - All in Moderation". Curr Med Chem 2022; 29:2235. 35. Dixit S, Stein PK, Dewland TA, et al. Consumption of Caffeinated Products and Cardiac Ectopy. J Am Heart Assoc 2016; 5. 36. Tran CT, Calkins H. Premature ventricular contraction-induced cardiomyopathy: an emerging entity. Expert Rev Cardiovasc Ther 2016; 14:1227. 37. Yokokawa M, Kim HM, Good E, et al. Impact of QRS duration of frequent premature ventricular complexes on the development of cardiomyopathy. Heart Rhythm 2012; 9:1460. 38. Park KM, Im SI, Lee SH, et al. Left Ventricular Dysfunction in Outpatients with Frequent Ventricular Premature Complexes. Tex Heart Inst J 2022; 49. 39. Voskoboinik A, Hadjis A, Alhede C, et al. Predictors of adverse outcome in patients with frequent premature ventricular complexes: The ABC-VT risk score. Heart Rhythm 2020; 17:1066. 40. Latchamsetty R, Bogun F. Premature Ventricular Complex-Induced Cardiomyopathy. JACC Clin Electrophysiol 2019; 5:537. 41. Huizar JF, Tan AY, Kaszala K, Ellenbogen KA. Clinical and translational insights on premature ventricular contractions and PVC-induced cardiomyopathy. Prog Cardiovasc Dis 2021; 66:17. 42. 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. Topic 994 Version 58.0 https://www.uptodate.com/contents/premature-ventricular-complexes-clinical-presentation-and-diagnostic-evaluation/print 14/23 7/6/23, 3:34 PM Premature ventricular complexes: Clinical presentation and diagnostic evaluation - UpToDate GRAPHICS 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-clinical-presentation-and-diagnostic-evaluation/print 15/23 7/6/23, 3:34 PM Premature ventricular complexes: Clinical presentation and diagnostic evaluation - 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-clinical-presentation-and-diagnostic-evaluation/print 16/23 7/6/23, 3:34 PM Premature ventricular complexes: Clinical presentation and diagnostic evaluation - 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-clinical-presentation-and-diagnostic-evaluation/print 17/23 7/6/23, 3:34 PM Premature ventricular complexes: Clinical presentation and diagnostic evaluation - UpToDate Single-lead electrocardiogram showing a ventricular premature beat The fourth beat is a ventricular premature beat (VPB). It has a wide, bizarre morphology, with a duration >0.16 seconds. Graphic 57511 Version 4.0 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-clinical-presentation-and-diagnostic-evaluation/print 18/23 7/6/23, 3:34 PM Premature ventricular complexes: Clinical presentation and diagnostic evaluation - UpToDate Electrocardiogram showing ventricular bigeminy A ventricular premature beat follows each sinus beat, and the coupling interval between the ventricular premature beat and the previous sinus QRS complex is constant (fixed coupling interval). The resulting pattern is referred to as ventricular bigeminy. Graphic 51529 Version 5.0 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-clinical-presentation-and-diagnostic-evaluation/print 19/23 7/6/23, 3:34 PM Premature ventricular complexes: Clinical presentation and diagnostic evaluation - UpToDate Single-lead electrocardiogram showing ventricular trigeminy Every third beat is a ventricular premature beat. The coupling interval between the ventricular premature beat and the previous sinus QRS complex is constant (fixed coupling interval). The resulting pattern is referred to as ventricular trigeminy. Graphic 64181 Version 4.0 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-clinical-presentation-and-diagnostic-evaluation/print 20/23 7/6/23, 3:34 PM Premature ventricular complexes: Clinical presentation and diagnostic evaluation - UpToDate Electrocardiogram (ECG) showing ventricular parasystole Unifocal parasystolic ventricular premature beats (VPBs) occur at a rate which is slower than the underlying sinus rhythm and manifest different coupling intervals (ie, the distance between the VPB and the prior QRS complex). The ectopic focus does not always activate the ventricular myocardium (and therefore does not produce a VPB on the ECG) since it may arrive at a time when the ventricle is refractory due to activation from the normal conduction pathway. However, the interval between two successive VPBs is always some integer of the underlying rate of the ectopic focus (the interectopic intervals have a common denominator) since the ectopic focus is undisturbed and continues to fire at its own intrinsic rate. Graphic 70928 Version 5.0 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-clinical-presentation-and-diagnostic-evaluation/print 21/23 7/6/23, 3:34 PM Premature ventricular complexes: Clinical presentation and diagnostic evaluation - 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-clinical-presentation-and-diagnostic-evaluation/print 22/23 7/6/23, 3:34 PM Premature ventricular complexes: Clinical presentation and diagnostic evaluation - 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-clinical-presentation-and-diagnostic-evaluation/print 23/23