Approach to treatment in patients with premature ventricular complexes (PVCs)

ACE: angiotensin converting enzyme inhibitor; ARB: angiotensin receptor blocker; BB: beta blockers; CCB: calcium channel blockers; CMP: cardiomyopathy; HF: heart failure; HTN: hypertension; PVC: premature ventricular complex/contraction.
* It is important to evaluate for potential PVC triggers as simple lifestyle changes may prove effective (eg, curtailing or eliminating alcohol, coffee or tea intake, or abstaining from recreational/stimulating drugs). Other triggers to be considered include electrolyte abnormalities, hypoxia, hyperadrenergic state, and uncontrolled hypertension.
¶ The evaluation for structural heart disease and primary electrical disease typically includes close scrutiny of a 12-lead ECG as well as an echocardiogram and, in selected cases, exercise stress testing and/or cardiac magnetic resonance imaging.
Δ If monotherapy with BB or CCB results in minimal or no change in symptoms, stop the initial agent and consider trial of monotherapy with agent from the other class.
◊ Patients with a cardiomyopathy, with or without HF symptoms, should not be treated with CCB. Patients with a cardiomyopathy who do not promptly respond to BB therapy (ie, reduction in PVC burden and improvement in left ventricular ejection fraction) should be referred for catheter ablation.
§ For patients with ongoing PVC-related symptoms following initial medical therapy, or for those who do not tolerate medical therapy due to adverse effects, we suggest catheter ablation, rather than antiarrhythmic drug therapy, as the next treatment. However, for patients without structural heart disease, either catheter ablation or initiating a class IC antiarrhythmic drug approach is a reasonable next choice, although the long-term efficacy of catheter ablation is likely to be higher.
¥ Refer to UpToDate content on HF with reduced ejection fraction for additional details of standard HF therapies.
‡ Examples of underlying heart disease include CAD, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, etc. Refer to specific UpToDate content on the disorder of interest for additional treatment details.