Michael Emery, MD, Premature Ventricular Contractions When to be Concerned and Which Tests to Evalu

[Music] so I'm going to talk to you about premature ventricular contractions when to be concerned in which tests to evaluate so just to make sure we're all on the same page before we get moving what is a PVC it's a premature contraction originating from the ventricle it's often called wide and bizarre looks different than the standard because it follows a different pathway that t-wave is often in the opposite direction of the dominant QRS and that's a PVC there are different variations of them but that's a pretty good standard definition for us today so quick question no polling just to get you set up and because John asked me for a question when evaluating an athlete with PVCs greater than 2000 noted during a 24-hour period is associated with an approximately what incidence of structural heart disease so there are your choices keep those in mind write them down Aitch them in your brain see if we can answer as we go along so I'm going to start with our consensus statement that we've all helped craft over the years the International criteria for electric offic interpretation and athletes it's multiple times today and it should be ingrained in your brain and you're probably gonna see it again I'm gonna pick out the one little thing on PVCs right here in the red side more than two or excuse me two or more PVCs on a screen ECG probably warrants further investigation or why is that let's talk a little bit more how prevalent are ECGs specifically how prevalent are they on an ECG you remember our standard ECG is 10 seconds slice of that person's life it's not very long so how often do we stumble across the PVC large data set from Italy which we referred to multiple times suggested about 1% of all prospectively screened athletes have at least a single PVC that's pretty consistent with what we know from the general population in the literature how about more than that dr. dresner's data from the n-c-double-a study says that two or more PVCs on us cleaning 12 lead ECGs about a quarter of 1% so that starts to drop even more what about more than that on a screening 10-second ECG this data from dr. Merrick we've also heard speak says that three or more PVCs 0.05 percent so those start to become pretty rare how prevalent are they on a holter monitor then that's a 10 second slice of ECG what if we measure you for longer than that well the numbers start to go up actually quite substantially these are some selected studies from the 80s when they were studying this more commonly and it suggests anywhere from 6 to 70% of athletes have at least some ventricular ectopy on their 24-hour holter monitor that's a pretty broad range 6 to 70% there's obviously some selection bias here but again that's pretty consistent with the literature in the general population we think so is that different in athletes are they more common in athletes than the general population hasn't been studied head-to-head very much a few studies here from the 80s and early 90s suggest that PVCs aren't all that more common and athletic individuals than in control individuals it may seem like it but at least from an objective measure it's not more common so what are we worried about then when we see more than two PVCs on a standard screening ECG well it's the association with potential cardiac disease so things like hypertrophic cardiomyopathy dilated cardiomyopathy ARB sees myocarditis sarcoid those are the things we want to make sure that this higher burden of PVCs two or more on a 12-lead ECG we think aren't a hallmark of that when we can do things like echocardiogram Holter monitors and stress tests so we're going to talk a little bit about those more in detail first though before you do more tests you got to take more history history history history x' everyone has mentioned before things that can enhance that ventricular irritability alcohol illicit drugs stimulants there's a lot of adderall floating around in our athletes these days performance-enhancing drugs and maybe not Aleve performance-enhancing drugs but those over-the-counter supplements that pre-workout that pre-workout I'll say that again that pre-workouts have you heard some of these names for these pre-workouts the name induces ectopy I think female athletes play a particular role here because the hormonal changes that may increase some of these menstrual cycle are they pregnant are they on oral contraceptives important to start with that history then monitoring 24-hour holter monitor and really what we're worried about when we monitor someone is PVC burden what do we mean by that well this study from Biffy in early 2000 looked at 355 competitive athletes with ventricular tachyrhythmia and categorized their PVC burden into Group a group B and Group C and what they found and then that group with greater than 2,000 PVCs in a 24-hour period and particularly if they had at least one run of non sustained VT they found a pretty high incidence of structural heart disease about 30 percent there's the answer to question important to keep in mind because if we start to see that higher burden it can mean a couple of different things one it means maybe we need to dig a little deeper especially if our echo may be normal looking or borderline then we need to dig a little deeper than maybe our standard testing but also things like structural heart disease show up so in this study they found things like a RVC mitral valve prolapse myocarditis and dilated cardiomyopathy what about that PVC burden beyond just structural heart disease LV mass does having an increased LV mass increase your risk of ventricular arrhythmias we don't really think so because doesn't seem to be a higher incidence in athletes and this study also showed that LV mass index did not correlate with ventricular ectopy more specifically training induced myocardial hypertrophy and that's what you have to delineate training induced versus some pathological athletes heart verses cardiomyopathy there's this thing called PVC induced cardiomyopathy and that's the other thing we worry about and it may not be specific to athletes at least not in their current state but it could affect their future health so there is an incidence of excessive PVCs causing a cardiomyopathy how we define that can be a little ambiguous depending upon the study in general more than 10 to 20 thousand PVCs in a 24-hour period or more than 10 percent of your total heartbeats but that's not an absolute when we look over in the bottom right that's not gonna work we see that lower burdens less likely to have cardiomyopathies but there are still a fleet s-- and patients that have high PVC burden that never develop a cardiomyopathy and vice versa patients that have lower burdens of PVCs that seemed to have a PVD PVC induced cardiomyopathy and this is potentially correctable once you get to this point this is really kind of getting into the subspecialty weeds and I think it's important that you keep that in mind what about exercise stress testing we often talk about this a lot that this should be part of your paradigm and evaluating somebody with PVCs whether symptomatic or higher burden the thought process is if I can overdrive suppress that ectopic focus that they are at lower risk but caveats to keep in mind dr. baggage mentioned this earlier dr. Sharma is missing this it really needs to be a maximal stress test you really need to try to reproduce the physiology of their sport whether that's running rowing sprinting or biking that's what we want to see because that's what they're going to be doing so I want to spend some time with this study here this study came out of Italy and they took 5,000 283 young athletes consecutive athletes were evaluated in the Italian system they excluded 272 of them right off the bat with cardiovascular abnormalities and I think that's important because if you read into their paper 18 percent of these 272 with cardiovascular abnormalities particularly ARB see was initially suspected based upon exercise and do summon tricular arrhythmia excuse me so when you're evaluating using an exercise stress test that increase in ventricular arrhythmia auto races suspicion and yatta dig a little deeper so they eliminated those from this study they had 5000 without cardiovascular disease all of them got stress tests 367 or 7% had one or more PVC they kind of decided that less than 10 PVCs you're good together more than 10 PVCs couplets non sustained and tricular arrhythmia you are not good to go that was point one point seven percent and they followed them over three to 12 months basically they forced them into deconditioning 64 percent had their ventricular ectopy reduced about two-thirds about a third did not so they said that two thirds and had it reduced could go back but what do we really know about deconditioning one our athletes hated right try to convince an athlete to decondition what's the data behind it then if we're going to try to use it well Biffy has the two studies that shows that deconditioning actually reduces burden and that when you retrain them after deconditioning that ectopy does not come back but this studies interesting this came out just a few years ago this had about 100 a little over 100 athletes with higher PVC burden about two-thirds elected to continue with sport and one-third elected not to continue his sport and they reassessed them a few years later with again ultra monitoring it didn't seem to matter whether you continued with sport or didn't continue sport he just waited it out there PVC burden went down so that's kind of a mixed results maybe it gets better just by weighting whether they're active or not and it's not the deconditioning process maybe it is the deconditioning process PVC burden may not decrease or with activity or with your sedentary state but again it's not often acceptable for most of our athletes so that often doesn't factor in at least in the US because it's really hard to get them to do Keynesian conditioning so they had 13 that they felt didn't respond to deconditioning they convinced six of them to go to get RF ablations for those PVCs no complications from those guys we did the right thing seven of them did not consent to RF ablation they were disqualified from the athlete's system but what happened it in at least for them continued to participate in recreational sports without cardiovascular events or symptoms so that's interesting so it didn't seem no matter what I did to him out of these 367 not a single one had a cardiovascular event had symptoms on follow-up or had structural heart disease that's whether they had high burden low burden I D conditioned and didn't be conditioned them ablated them or didn't oblate them it didn't seem to matter as long as they didn't have structural heart disease so I think the key part here is part of exercise testing is to make sure things don't look worse and increase your suspicion of an underlying disease that they're asymptomatic without functional limitation again that's part of your stress testing to assess for functional limitations and without structural heart disease I'm going to move on to the big asterisk because there's an asterisk in there right consideration in high dynamic athletes and what is this concern about well when we talk about cardiovascular adaptations there's exercise as a stimulus that's the typical athletes heart we now know that exercise can facilitate genetic ARV C so it can bring out the AR vc phenotype and maybe potentially more aggressively then there's this less well-defined category which exercise is an inductor so that is this phenomenon that's starting to be described still somewhat controversial somewhat maybe even strong still controversy about exercise induced a RVC what there's some overlap between what looks like a RVC but we don't really see the genetics and maybe that high-intensity dynamic exercise over a longer period of time may bring this out so that's where the asterisk comes in to in the guidelines what it says is cyclists triathletes rowers over the age of 25 so we think it takes time then to develop this if it's if it's something that's going to be of concern with one or more PV C maybe you ought to think about evaluating those even though they only had one PVC and a screening EKG particularly what they have a left bundle branch morphology with superior axis which is this which is the downgoing QRS and the inferior leads that's the a strict so investigation of athletes with PVCs this is a nice flow gram from dr. Sharma's paper echocardiogram yes or no normal echo ECG stress test low burden normal exercise capacity nothing else that raises your suspicions for underlying cardiovascular disease you're pretty much good to go at least for now as long as you don't even chew aliy develop symptoms in the future that would warrant for the evaluation guidelines from the accha basically says that single PVCs or complex forms no more than couplets that don't get worse with exercise and are asymptomatic you're generally good to go if they increase in frequency or you become symptomatic then you need to look harder for a true cardiomyopathy process if you discover a structural abnormality that's causing the PVCs or responsible for the PVCs then you treat them like the underlying disease state that's causing that and there is some room for catheter ablation of symptomatic PVCs without structural heart disease in these athletes thank you [Applause] you

Channel: UW Medicine Center for Sports Cardiology

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Id: x_8TCXh_14U

Length: 14min 42sec (882 seconds)

Published: Fri Apr 20 2018