PAC and PVC:

Treat it or Leave it ?

Jogja Cardiology Update 2017

Dr. Ardian Rizal, SpJP(K)

Cardiology and Vascular Medicine
Faculty of Medicine, Brawijaya University
 Outline

Introduction ECG Clinical Importance Management Role of Holter

o PAC : Basic and
Advance
o PVC : Basic and
Advance
INTRODUCTION
Introduction

Normal / abnormal ?

Treat or Leave it ?

What to do Next ?

Jogja Cardiology Update 2017

 PAC & PVCs in Numbers

40–75%
In General
1.39 3.5%
incidence of
Mostly
Only need
Population Male compared sustained
to female reassurance
VT or SCD
ECG
PAC & PVC
ECG

Jogja Cardiology Update 2017

 PAC : 4 Main Characteristics
• They are premature
- earlier than you would expect

• They are ectopic

- originating outside of the SA node

• They are narrow complexes

- aberrant conduction

• There is a compensatory pause after the PAC

Jogja Cardiology Update 2017

PAC

Jogja Cardiology Update 2017

 PAC : 3 Fates

Atrium

AVN
RBRB
LB

Ventricle

Jogja Cardiology Update 2017

 PAC : Another Features

• The P wave typically has a different morphology and axis to the sinus P waves.

• The abnormal P wave may be hidden in the preceding T wave, producing a

“peaked” or “camel hump” appearance — if this is not appreciated the PAC may
be mistaken for a PJC.

• PACS arising close to the AV node (“low atrial” ectopics) activate the atria
retrogradely, producing an inverted P wave with a relatively short PR interval ≥
120 ms (PR interval < 120 ms is classified as a PJC)
Jogja Cardiology Update 2017
PAC : Another Features (cont’d)

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PAC : Detailed Location

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ECG

Jogja Cardiology Update 2017

PVC

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PVC

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PVC

Jogja Cardiology Update 2017

 Different Morphology, Different Location
VT localization :  RBBB/LBBB morphology:
General
VTPrinciple  RBBB:
Localization: General ECG origin in the left ventricle
Principle
 LBBB: origin in the right ventricle
1.  Inferior/superior axis (lead II, III and
LV free wall VT shows RBBB
aVF):
configuration, while VT
exiting from IVS or RV
displays LBBB configuration.
2.
 Inferior axis (positive in lead II, III and aVF):
Septal exits are associated
origin superior
with narrower QRS wall
consistent with synchronous
 Superior
rather axis (negative in lead II, III and
than sequential
aVF):activation.
ventricular origin inferior wall
3. Basal sites show positive
 Basal/apical (lead V5-V6):
precordial concordance,
while negative concordance
 Positive
is seen in apicalconcordance
sites of in V5-6: basal origin
 Negative concordance in V5-6: apical origin
origin.

Jogja Cardiology Update 2017

8
 PVC in Normal Heart
• Also called Idiopathic
VT/PVC
• Mostly Outflow tract
VT (90 %)

Inferiror Axis LBBB Type

Jogja Cardiology Update 2017

Clinical Importance
 Clinical Importance : PAC
• Most individuals with premature atrial complexes have no organic
heart disease
• The premature complexes tend to occur more often when atrial
disease or atrial enlargement is present.
• They are known to precede the establishment of atrial flutter or atrial
fibrillation

Jogja Cardiology Update 2017

Clinical Importance : PAC (cont’d)

Jogja Cardiology Update 2017

 Clinical Importance
PVC

Reassurance
Asymptomatic and Benign

Frequent and Symptomatic

ICD and
Ablation
Sudden Cardiac Death

Heart Rhythm, Vol 11, No 10, October 2014

 PVC
Diagnosis Work UP

12 Lead ECG & Specific Morphology

Structural heart disease ?
Echocardiography
inherited and acquired cardiomyopathies?
Holter Monitoring
myocardial ischemia ?
Other imaging
 Expert Consensus EHRA/HRS/APHRS
Diagnosis Work UP
• All patients should have a resting ECG and echocardiogram to detect underlying
heart disease including inherited and acquired cardiomyopathies. Especially in
patients in whom the arrhythmia morphology suggests such a specific etiology
(II a ; LOE B)

• A test for myocardial ischemia should be considered in all patients with VAs in
whom the clinical presentation and/or the type of arrhythmia suggests the
presence of coronary artery disease. (II a ; LOE C)

• Prolonged ECG monitoring by Holter ECG, prolonged ECG event monitoring, or

implantable loop recorders should be considered when documentation of
further, potentially longer arrhythmias would change management. (II a ; LOE C)

Heart Rhythm, Vol 11, No 10, October 2014

 PVC
Induced Cardiomyopathy
• Several studies have demonstrated an association
between PVCs and a potentially reversible
cardiomyopathy

• Risk predictors :
• high-frequency PVCs
• longer duration of PVCs
• epicardial or broad QRS complex PVCs
• interpolated PVCs
• male sex
Rev Esp Cardiol. 2016;69(4):365–369
Management
Management of PVCs
 Treatment
In Structural Normal Heart
• The first step is education of the benign nature of
this arrhythmia and reassurance

• The most common indication for treating PVCs

remains the presence of symptoms

• Medical tx :
• Beta – blocker and non-dihydropyridine calcium
antagonists
PVC/NSVT Management
in Normal Heart

Jogja Cardiology Update 2017

PVC/NSVT Management
in Structural Heart Disease

Jogja Cardiology Update 2017

 Catheter Ablation
• catheter ablation should only be considered for patients who are markedly symptomatic
with very frequent PVC

• Multiple studies indicate high efficacy of ablation with PVC elimination in 74 – 100% of
patients

• Procedural success may be dependent on site of origin and number of PVC morphology

• Although complete PVC elimination is the goal of ablation, it should be noted that partial
success may still be associated with significant improvement in LV systolic function

• Catheter ablation for idiopathic ventricular tachycardia For focal VT (esp RVOT VT) 
highly successful and carries low procedural risk

Jogja Cardiology Update 2017

Role of Holter
Monitoring
Ambulatory ECG Monitoring

Jogja Cardiology Update 2017

Jogja Cardiology Update 2017
Case
• Man 65 y.o. frequent palpitation, Prior CAD and CVA
Case
• Girl 12 y.o.
• Frequent
episode of
palpitation
Jogja Cardiology Update 2017
TERIMA KASIH