#018 What Causes PVCs and How to Stop PVCs

July 14th, 2014 by

What Causes PVCs and How to Stop PVCs

Most people get a premature ventricular contraction (PVC) from time to time. Is this something dangerous? What causes PVCs?  How do you stop PVCs?

Lisa’s Experience with PVCs

Lisa came to see me for disabling palpitations. She had always been in excellent health. She exercised regularly and ate a healthy diet. Now at the age of 34 she was having severe palpitations. How could this be?

If you think about it, the heart is an amazing organ. It beats 100,000 times a day. Most of the time, every heart beat is perfectly timed.

Sometimes, the heart fires prematurely. If you are taking your pulse at the time this happens the premature beat is not detected and it feels as if you have skipped a beat. You can see this clearly on the EKG with this article. Every third beat is a PVC which is characterized by a big wide electrical signal from the lower chambers of the heart.

For 99% of the population, they do not feel these premature beats. For others, they feel each and every misfire and it causes them severe symptoms.

You can have a premature beat arise from either the upper or lower chambers of the heart. If the premature beat is arising from the upper chambers of the heart it is called a premature atrial contraction (PAC) and if it is from the lower chambers of the heart it is called a premature ventricular contraction (PVC). Fortunately, 99% of the time, these are totally benign!

In Lisa’s case, she would have chest pains, shortness of breath, palpitations, dizziness, and nausea whenever her heart was skipping beats. Sometimes she would describe this as “hard beats.” It seemed like her palpitations always got worse around the time of her menstrual cycle.

To figure out what was going on, we put her on a Holter heart monitor for 48 hours and scheduled her for a stress echo. A stress echo is a treadmill stress test with a cardiac ultrasound.

The ultrasound of the heart, also known as an echocardiogram, is done before exercise and then repeated at peak exercise. The purpose of the stress echo is to make sure there is nothing structurally wrong with the heart that is causing the PVCs.

I personally like the stress echo because no IV is needed and there is no radiation with this test. It can also be helpful to see what happens to the PVCs with exercise.

In Lisa’s case, the Holter monitor showed that 20% of all her heartbeats were PVCs. Fortunately, her stress echo was totally normal.

Lisa was still worried as she had 3 small children.  Thus, in her case, we also did a cardiac MRI.  Once again, this test was fortunately normal as well.

What causes PVCs?

As you might imagine, Lisa wanted to know what was causing her PVCs. Structural heart disease, like a blockage in an artery of the heart or even heart failure, can certainly cause PVCs.

Most of the patients who come to see me for PVCs, like Lisa, want to know what is causing their condition.  And, as a cardiologist, this is the most important question to answer.  Is there something dangerous causing the PVCs?

Fortunately, Lisa did not have any structural heart disease.  I should point out here that PVCs seen with an abnormal stress echo or cardiac MRI are the PVCs we worry about most.  PVCs associated with structural heart disease are the PVCs which can cause a cardiac arrest.

If there is no structural heart disease then the PVC’s are generally felt to be benign unless the burden of PVCs is significant–like 20% or more of the total heart beats.

For people without structural heart disease, like Lisa, with her normal stress echo and MRI studies, we often do not know the exact cause of PVCs. For whatever reason, one particular cell or a cluster of heart cells, will spontaneously kick off these electrical signals. These PVCs often wax and wane in intensity over the years.

In many cases, lifestyle modification can cause the PVCs to go away or improve.  Of all the lifestyle changes that can be made for symptomatic PVCs, the most important is stress management.

When do you worry about PVCs?

Fortunately, for the 99% of the patients I see with PVCs, this condition is completely benign. As mentioned at the beginning of this article, every living and breathing human being has PVCs.

Fortunately, 99% of the population can’t feel their PVCs.  Thus, regardless of how PVCs are treated (lifestyle modification, medications, or ablations), you will never be able to make 100% of the PVCs go away.

PVCs are a part of the human condition.  The heart will simply misfire from time to time.

We worry about PVCs in the following three situations:

1. Structural heart disease is present.

This could be a weak heart (heart failure), a significant cardiac valve problem, a blockage in an artery of the heart, etc.  Structural heart disease is something that picked up on a stress echo or cardiac MRI.

2. Genetic Abnormality

There are certain genetic abnormalities that can cause PVCs but yet are sometimes not picked up on a stress echo or a cardiac MRI.  Genetic testing has now become quite affordable and is something we may consider in PVC patients with a family history of a cardiac arrest.

As Lisa had no family history of cardiac arrest and her stress echo and cardiac MRI were both totally normal, we decided not to pursue genetic testing as it would most likely not help.  Also, genetic testing potentially opens us people–like from life insurance companies.

3. When PVCs comprise 20% or more of the total heart beats.

When 20% or more of the total heart beats are PVCs, we start worrying that perhaps the PVCs could cause heart failure.

In Lisa’s case, as she had severe symptoms from her PVCs, we knew we had to do something so that she could get her life back. For most of the patients that I see with PVCs, just knowing that they don’t have too many PVCs (less than 20%) and that their heart is otherwise normal (normal stress echo), they can live with the benign PVCs. For my patients with a lot of symptoms from PVCs, like Lisa, we start with the following to stop their PVCs.

How to Stop PVCs

1. Get Stress Under Control

For many patients, just knowing their PVCs are benign takes care of the problem and relieves the stress. I have found over the years that my patients who are most bothered by PVCs are often my most anxious patients.

When you are stressed the body releases adrenalin and cortisol, among other stress hormones. These stress hormones put a strain on the heart and can trigger PVCs. I have seen many cases of severe PVCs that have all resolved once the patient gets their stress and anxiety under control.

One question that often comes up is did the anxiety cause the PVCs or are the PVCs causing the anxiety.  Depending on the case, both are probably true.

There is some fascinating research being done by my good friend, Dr. Shivkumar, at UCLA on cardiac nerves.  His recent studies show that PVCs may activate cardiac nerves which then send signals back to the brain.  These findings could help to explain why some people, who have never suffered from anxiety before, suddenly became anxious at about the same time their PVCs symptoms first appeared.

Regardless of the cause, if you suffer from stress or anxiety the first step is to get this under control. Do something each day to relieve stress.

For example, yoga has been shown to be very helpful in controlling arrhythmias. Daily meditation is also highly effective.  For more information, please read my article (Blog #14), Eliminate Stress in Seven Steps.

2. Eliminate Stimulants and Other Vices

Do you consume a lot of caffeine? Do you take stimulant cold medicines, ADHD medications, or stimulant inhalers for asthma? Do you use any nicotine products, alcohol, or recreational drugs?

Any stimulant can trigger PVCs. Stimulants cause release of adrenalin which can trigger PVCs.

To learn more about the effect of caffeine to PVCs, please read this article I recently published.

3. Get Enough Sleep

Amazingly, many of my PVC patients just do not get enough sleep at night. With sleep deprivation, your stress hormones go way up which can trigger PVCs. Have a set sleep schedule and get at least 7 hours of rejuvenating sleep.

If you are overweight, or have a neck size of 17 or more in a man (16 or more in a woman), you may have sleep apnea. This is a condition where people snore loudly at night and periodically stop breathing. This causes oxygen levels in the body to plummet and can be another cause of sleep deprivation and PVCs.

If your spouse or sleeping partner tells you that you snore, or that you sometimes stop breathing in your sleep, talk to your doctor now about getting tested for sleep apnea. Fortunately, most cases of sleep apnea are reversible with weight loss.

If you are struggling with getting at least seven hours of rejuvenating sleep, please read my article (Blog #16) Ten Ways to Cure Insomnia without Medications.

4. Eliminate Your Triggers

You may have additional triggers besides stress, stimulants, or sleep deprivation.  For example, some people may have the vagal triggered form of PVCs.

Vagal PVCs are triggered by activation of the vagus nerve, like after a big meal or eating certain foods.  Often, by avoiding your gastrointestinal triggers or by getting the gastrointestinal system under control, the PVCs may subside.

5. Eat a High Potassium and Magnesium Diet

Just making sure you are getting enough potassium and magnesium in your diet may be all that is necessary to get PVCs under control. These electrolytes have a calming effect on the cells of the heart.

Fortunately, the foods highest in potassium and magnesium are the healthiest foods. However, people suffering from kidney disease should be careful with high potassium and magnesium foods.

In addition to bananas, other excellent sources of potassium include spinach, beans, broccoli, and cantaloupe. To learn more about which foods are highest in potassium, please visit whfoods.

For magnesium, the best sources are nuts, seeds, and “greens.”  Some examples of foods high in magnesium include pumpkin seeds, spinach, and beans. To learn more about which foods are highest in magnesium, please visit whfoods.

6. Too Little or Too Much Exercise

As with most arrhythmias, not getting enough exercise or extreme exercise (marathon or ultra marathon running, long distance competitive cycling, triathlons, etc.) can trigger PVCs. I recommend at least 30 minutes of moderate intensity exercise or 15 minutes of high intensity exercise AND 10,000 steps, as confirmed by a pedometer, each day for my patients.

For those people who enjoy extreme levels of exercise (marathoners or ultra marathoners, long distance competitive cyclists, triathletes, etc.), it may be that you need to scale back your exercise to get PVCs under control.

If you have not been exercising regularly, talk with your doctor first before starting an exercise program.

7. Keep Your Blood Pressure Under Control

For some of my patients they find that when their blood pressure spikes high they are more likely to experience PVCs. The goal blood pressure, as established by the American Heart Association, is 120/80 mmHg.

If your blood pressure often reads higher than this, please work with your physician on getting your blood pressure under control. Please also read my article (Blog #12) Lower Your Blood Pressure with These Eight Steps.  Another great article I wrote is 10 Ways to Lower Your Blood Pressure Naturally.

8. Work with Your Doctor in Treating Other Medical Problems

Often PVCs can be triggered by other medical conditions. For example, asthma, sleep apnea, COPD, heart failure, or coronary artery disease can all trigger PVCs. Work with your physicians in getting these conditions under control.

9. Work with Your Doctor to Change or Eliminate Other Medications

Sometimes other medications can trigger PVCs. For example, diuretics or water pills cause you to lose electrolytes. Electrolyte depletion can trigger PVCs.

You may also be on a stimulant medication, such as those used to treat asthma, COPD, ADHD, etc.

Medications that lengthen the QT interval on the EKG can also trigger PVCs. These include many antibiotics, antidepressants, and other medications. For a list of many of the medications that lengthen the QT interval, please check this list of medications.

10. You May Need a Medication to Help with PVC Symptoms

In rare cases, my patients are so bothered by PVCs that we need to try a medication when numbers 1-8 above do not work or when patients are unable to make the necessary lifestyle changes. As 99% of the PVC cases I see are totally benign, I am always hesitant to start someone on a potentially life-long cardiac medication.

Often, the side effects from one of these medications is worse than the PVC symptoms. If we must try a medication, I generally start with a beta-blocker. I find that in about half of the patients I see, beta-blockers help with PVCs.

In rare cases, when beta-blockers don’t work and patients tell me that they cannot live another day with PVCs, I may try an anti-arrhythmic. Anti-arrhythmics always make me nervous as they can increase your risk of a cardiac arrest or premature death.

11. When All Else Fails an Ablation May Be Necessary

For those patients with a high burden of disabling PVC symptoms (more than 20% PVCs on a Holter) that have not resolved with numbers 1-9 above, we may perform an ablation procedure. In an ablation, we go in to the heart with a catheter, map out the source of the PVCs, and then cauterize or freeze the areas of the heart kicking off the PVCs.

I find that the most challenging part of the procedure is getting the patient to have enough PVCs during the procedure. It is for this reason that we like to see at least 20% PVCs on a Holter monitor before even recommending this procedure. If PVCs are happening frequently during the procedure then the PVCs can often be cured in 80-90% of the cases.

In Lisa’s case, her PVC symptoms resolved with lifestyle changes. While the PVCs never completely went away, she was no longer bothered by the PVCs.  Her PVC burden went from 20% on a Holter monitor down to just 1% with lifestyle changes.

It is important to remember that everyone will get a PVC from time to time. When the heart beats 100,000 times each day it is bound to occasionally misfire. This is a normal thing.

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