PVCs after AMI

[Fran71]

Dear Doctor,
my father, 69, had an AMI at 65. He had a fast recovery and is doing great eversince. Recently his GP ordered holter monitoring, which showed over 1900 PVCs of 2 morphologies with 6 couplets! No NSVT or VT, no ST changes indicative of ischemia, mean HR 65, no tachy or bradycardia. It’s amazing he doesn’t feel any of the PVCs. He quit smoking after his AMI, doesn’t have comorbidities, annual echos and stress tests have always been judged OK. He’s on the usual meds prescribed after AMI. He’ll see his cardio soon, meanwhile I wonder:
1. I know PVCs with CAD can be malignant. I also read antiarrhythmic agents in these patients actually increased mortality. How would you manage a case like this? Should his PVCs be suppressed? Would he be a candidate for a defibrillator or ablation?
2. If PVCs with CAD carry such a negative prognosis, can you guess why none of his cardios – he saw at least 3 since his AMI – never mentioned he should have a holter performed?
3. We’ve always been told his AMI did little damage to his heart because he was at the ER when it occurred and underwent thrombolysis within minutes. Do his frequent complex PVCs prove otherwise? Do they necessarily mean his heart is in bad shape?
4. Should he stop exercising (30 min daily on the bike or slow walk) or take other precautions?
5. All the studies I found (like the GISSI studies) seem to relate to the importance of PVCs occurring immediately after AMI. Does their impact on prognosis change 4 years after a heart attack?

Thank you so much for your time!!

Fran

[Forum-M.D.-MM]

Hi Fran,

Sorry to hear about your father heart attack.


1. I know PVCs with CAD can be malignant. I also read antiarrhythmic agents in these patients actually increased mortality. How would you manage a case like this?

Standard post heart attack care is appropriate: cholesterol control, blood pressure control (ace inhibitor, beta blocker), no tobacco

Should his PVCs be suppressed?

Beta blockers are sufficient.

Would he be a candidate for a defibrillator or ablation?

If he isn't having symptoms or sustained VT, I would not do an ablation.  If his ejection fraction is less than 35% and he meets certain criteria or if his  EF is less than 30 %, he would qualify for a defibrillator.

2. If PVCs with CAD carry such a negative prognosis, can you guess why none of his cardios – he saw at least 3 since his AMI – never mentioned he should have a holter performed?

That is a tricky question.  There is not treatment for PVCs post MI other than beta blockers.  You are correct that the CAST study showed that PVC suppression with class I antiarrythmic is detrimental.  What you are left with is a risk factor with no strong treatment options.  Two similar questions are would you want a genetic test that showed  you are at higher risk to develop cancer or some other disease without any way to treat it?  Then you are left with the worrying about PVCs with no treatment.   Being male is also a risk factor for coronary diease and cardiovascular events -- there are just some risk factors we cannot change.


3. We’ve always been told his AMI did little damage to his heart because he was at the ER when it occurred and underwent thrombolysis within minutes. Do his frequent complex PVCs prove otherwise?

No, PVCs do not mean the damage was more extensive.  An assessment of his ejection fraction can estimate the size of the infarct.  

Do they necessarily mean his heart is in bad shape?

Absolutely not.

4. Should he stop exercising (30 min daily on the bike or slow walk) or take other precautions?

I don't know enough about him to answer this question.


5. All the studies I found (like the GISSI studies) seem to relate to the importance of PVCs occurring immediately after AMI. Does their impact on prognosis change 4 years after a heart attack?

PVCs are an indicator of increased cardiovascular events in patients with heart disease just like hypertensin, diabetes, increased cholesterol, smoking, being male, etc.  Unfortunately that is about all we know.  We don't know how to further risk stratify patients at this point.  I don't think you need to worry about it tough.  You might not like this answer, but it is one of those things that we cannot change for now and aren't 100% sure of its significance.  Try not to worry to much about this -- especially if your father doesn't.

I hope this helps.  Thanks for posting.


Thank you so much for your time!! Fran

[tickertock]

Hi Fran,

This is a great question. I have a cousin 52 years old who was a heavy smoker that had an MI in May last year.He presented to the ER with tightness in the chest , profuse cold sweating very frequent PVCs and occasional VTach. He was air lifted via air ambulance where he was stablized and a drug coated stent place in his RCA 2 days later which was 70% blocked, all other coronary arteries was clear. He suffered moderate heart muscle damage. He was released while still having frequent PVCs though the Vtach cleared up with an Ef of 35-40% at maximal estimation.

That was nearly a year ago, he still gets frequent PVCs, though he only feels a few, never felt any before his MI. He gets tired much quicker than before, given the usual meds, beta blocker, ace inhibitor, statin, plavix and aspirin.

Despite his frequent PVCs after MI, the cardiologist has reassured him that despite his reduced Ef and PVCs , his risks are only slightly increased mainly because of the Ef and not the PVCs and has given an overall favorable diagnosis with life style changes and medication.

One plus your father has apparently after 4 years he's still doing fine with no other complications, hope he continues to do well.

Statistically speaking, as I understand it, a person that has suffered an MI and has frequent PVCs is at more of risk, but I think it depends on the overall picture and not just the PVCs by themselves. Take care and I'll check in with ya soon.

[Fran71]

Thanks, doctor, for taking the time to write such a long, informative answer. Your words are very wise and also encouraging, though surely realistic. I now know we're doing the right thing.

And you guessed right - my father doesn't worry about this! Only I do.

Thanks again and take care

Fran

[Fran71]

Hi there! Sorry about your cousin. Glad his prognosis seems good. Thanks so much for posting. Yes my Dad seems to be doing OK. I think his EF is in the norm. He actually says he feels better now than before the AMI, as he now doesn't smoke, eats healthier and exercises regularly.
Like the doctor says, there are factors we cannot change. Maybe it had been better if I hadn't known the holter results as there's little we can do...But I'll try not to worry about this.

Keep in touch!

Fran

[myowncrazybeat]

Sorry for the question...

Why would PVC's be dangerous in a person with known CAD?  I thought most doctors weren't worried about PVC's or PAC's, saying they were more of a nuisance than a problem.

I appreciate any input.  My grandfather has "skips" and he is about 10 years post quad bypass.  His PC and Cardio aren't the least concerned.

Thanks very much!  Glad your families are well!

[Fran71]

Hello, I'm not sure why PVCs would be potentially dangerous in patients with CAD, maybe somebody can explain? However studies have shown that people who have had an AMI and have frequent PVCs are at higher risk of fatal arrhythmias. Hearing your grandfather is doing so well in spite of his skips is very encouraging for me!

Thanks

[anacyde]

I know that someone with a reduced ejection fraction can be at a higher risk from PVCs due to the risk for other, more serious arrhythmias developing - but this is because the heart isn't functioning properly in the first place.

I'm interested in hearing why PVCs increase risk in people with CAD too.  My husband is 39 and has dangerously low HDL.  His brother suffered a massive, near-fatal MI at 40.  Needless to say we're doing all we can to manage risks.  My husband does experience fairly frequent PVCs, though his EF is normal (55-60%) and he does not have known CAD himself.