Significance of PVCs during and after exerxcise

Thanks for taking my questions as usual. There has been much debate on the forum lately about studies showing an increased risk of death with PVCs after exercise, I know the doctor was kind enough to give us some insight into understanding this study.

In simple terms, in your opinion does PVCs at rest , during or after exercise increase the risk of death in a structurally normal heart? I myself tend to get exercise induced PVcs, but they are less frequent after exercise so this subject interests me very much . I must say that I am taking atenolol 25mg of atenolol 4 times daily, prescribed 50mg twice daily, but I find that 25mg of atenolol 4 times daily appears to be more effective, I still get the 100mg daily, my internist agrees with this approach if I find it more effective that way. To add I rarely get PVCs now, so I assume the medicine is working, I also take Cozaar 50mg daily, this also sames to suppress the PVCs when combined with atenolol, Are you aware if Cozaar might actually have anti arrhythmic effects when combined with atenolol, could be coincidental , just wondering?

  I also understand that some persons with a normal heart has exercised induced ventricular tachycardia, it is my understanding that this type of tachycardia is usually "benign" and the the risks of sudden death with this condition is very , very small, almost negligible(sp), even though I hate to use that word, could you confirm if my understanding of this is correct?

  Is it true that atenolol is very effective in suppressing exercised induce VT in some studies.



      
  

[CCF-M.D.-RCJ]

pluto,

Thanks for the post.

Q:"In simple terms, in your opinion does PVCs at rest , during or after exercise increase the risk of death in a structurally normal heart?"

A qualified No.  If they only occure after exercise, then perhaps to the risk of death is marginally increased, but probably not because of a direct PVC effect, but because of some as yet unknown association.

Q:"Are you aware if Cozaar might actually have anti arrhythmic effects when combined with atenolol, could be coincidental, just wondering?"

I am not aware of an association.  However, the cousin group to ARBs (like Cozaar) is ACE-inhibitors, which have been shown to decrease the incidence of afib in persons with heart failure.

Q:"could you confirm if my understanding of this is correct?"

Yes, you are correct.

Q:"Is it true that atenolol is very effective in suppressing exercised induce VT in some studies."

Beta-blockers are used to treat some patients with normal heart VT, and the efficacy can be quite good.

[fizzixgal]

I will be interested in the answer to this too. Don't know about VT in a normal heart being benign... as I recall, triathlete Greg Welch was considered in mortal danger from VT and forced to quit competition even though no underlying disease was found. And his conditioning made him better able to tolerate sustained VT than most of us would be.

I was on metoprolol briefly, prescribed bid but had to go qid too for the same reason, my body metabolised it at a faster than average rate. If I hadn't been switched to verapamil, I would have insisted on Toprol XL. I don't know if atenolol is available in extended release, or if you've considered metoprolol or any of the nonselective blockers (nadolol has a >18 hour half life).

[30something]

Wondering what Studies show an increased risk of death with PVCs after exercise.  All the doctors tell me everything is good as long as you dont have PVCs during exercise.  Mine get really bad after exercise. Should I be concerned? Can you name the studies you make referrence to?

[Momto3]

Here is a link to the copy of Dr. Michael Lauer's study from the CCF.  It gets to the "heart of the matter." : )
http://www.healthfinder.gov/news/newsstory.asp?docID=514906
Connie

[fizzixgal]

Sorry, I meant nadolol is nonselective. Metoprolol and atenolol are both cardioselective (except at higher doses). Interesting about atenolol as I thought it was considered the longest-acting of the cardioselective blockers, thanks.

My point about Welch is that his risk was not considered small, he was told he was "as good as dead" if he didn't stop. Maybe the consensus has changed since then, or maybe what you say is true for NSVT but not for sustained VT.

[30something]

Thank you. I will bring a copy to my next cardio apt.  

Noticing you nickname is momto3, and assuming you have 3 kids, may I ask if you had pvc's during pregnany? I just learned I am pregnant and the pvc's are pretty bad now. Any suggestions/ comments on how pvc's relate to pregnancy? (Sorry to bring this up here)

[michi]

hi,

i had been pregnat the last 3 month of 2003. in that time i expierenced a mild increase of pvc/pacs. i also developed i strongly believe afib. in those 3 month i had 2 attacks for about an hour of a really crazy heartbeat no rythmn at all.
when i lost the baby i had chestpressure for a longer time and everything went away. just last week i had one short episode for about 4-5 secs. of a crazy rhythmn again.
good luck

michi

[Momto3]

Oh yeah! The pvcs were very prevalent throughout pregnancy. That being said, I am happy to say the pvcs did not seem to have any negative effect as to the pregnancy, labor, delivery, etc.  CONGRATULATIONS!!

Interestingly, when I considered a 4th pregnancy (in my younger days...hahaha), the doctors cautioned me ever so slightly, but it may have been because of mitral regurgitation.  Not sure....When is your baby due?

[Dr. Erik]

Sometimes when I exercise I get PVC's but most of the time I don't. Sometime's I get PVC's after I exercise but most of the time I don't. Sometimes I'll be geting PVC's and I'll start to exercise and the PVC's will go away. There never is a pattern . It's different every time. When I never used to exercise I would have good days and bad day's with my PVC's. I think people will get PVC's whether they exercise or not. We know that PVC's in a normal heart carries no higher degree of mortality. I say what's the difference if get them during or after exercise if we had them to begin with. I had PVC's on a stress test once. Then a couple years later I didn't have any on another stress test. Does that mean my mortality rate was higher during the first stress test than during the second stress test? It sounds stupid to me. I don't buy into this higher mortality business. My cardiologist doesn't either. Incidently, the past year that I have been exercising I have noticed a vast decrease in my PVC's and have had no more episodes of A-Fib. I think that exercise reduces mortality more than PVC's during exercise raises it. Just a thought. The very best to you!

Erik

[Mel22]

Sometimes I'll get a PVC or two with exercise, but most of the time I will not. If I exercise after I have had onions in the last 24 hours, I have a greater chance of having PVCs. In fact, onion ingestion is the greatest single factor of whether or not I will have a PVC, regardless of activity. Go figure.

[Momto3]

I have also had pvcs just about anytime.  Most stress tests started out with "transitional pvcs" and by the time I was well into the test, my heart was pumping ever so efficiently.  Years ago a cardio remarked that all I had to do was keep running around and I would have less pvcs...

The overall benefits of exercise (in the general population) cannot be underestimated. Talk with your doctors and determine if exercise is safe or not and then "run with it!"  LOL!

Be careful to listen to your own doctor. If he/she thinks your pvcs/pacs are medically significant he/she will let you know.  Best advice for those buggers is to try and find personal coping methods.  If the ectopics become unbearable or medically significant, talk with your doctor and decide how to move forward.

I've tried beta blockers, ant-arrythmics (not really by choice) and ablations.  For me, the ablations were the most beneficial. But every situation is unique.  Stay healthy everyone : ) connie

[Mieke]

I am too a PVC sufferer, have been for over 20 years now.  Your question about PVC's and pregnancy reminded me of my last pregnancy.  During the first 20 weeks my PVC's were awful and very distressing and then when I got to 20 weeks they disappeared altogether!!  So the last 20 weeks of my pregnancy were great, I thought I had got rid of them for good.  Everything went well with the delivery but unfortunately a couple of day later they came back.  I was so upset, saw a cardiologist, had holter monitor etc but no explanation as to why this had happened. I was diagnosed at the time though as having a Mitral valve prolapse.  I wonder if the fact that when my stomach got larger it somehow took some pressure off or moved something so my heart wasn't irritated?  I never have found an explanation for it. I hope you get some relief from your PVC's during your pregancy.

[Mel22]

It always helps to know we're not alone. Or crazy.

Thanks! ;-)

[fizzixgal]

Hank, yup, I hear what you're saying about VT and I'm aware of that. You could be right, let's wait for the doctor's answer.

Connie, thanks for the link, very interesting article. I wonder if they broke down the risk associated with different kinds of abnormal heart rate recovery (e.g. abnormally prolonged vs non-monotonic return to baseline vs different kinds of ectopy).

I've also had "transitional pvcs" that disappear later. When my palps are exercise induced it is after short, ordinary activities like walking a block or two. They actually stay away for hours after long brisk walks and bike rides. But sometimes they return  much later with a vengeance (like last night).

[Momto3]

Just wondering if anyone experiences palps during an exercise workout on gym equipment. Even though my palps have nearly disappeared, I do experience them just like old times if I do any weight training.  If I use upper body muscies, here they come...Just curious if others have same problem.

Fizzixgal....Don't know how they broke down the study, but you may be able to find out more on the CCF.org webpage.  You can read about the current and past research and clinical trials. Fortunately, my HR recovery falls within the normal range...YEAH for that!! Hey, I just figured out something (I think)...You are a "physics" gal, right?  I'm slowin' down in my "old" age..lol

connie

[fizzixgal]

Thanks, I'll check out the site. I was just wondering 'cause though I've never been told mine was abnormal, I've seen my HR plateau and go back up slightly, then start down again. This is usually when I've gotten my HR above around 140 where it hasn't been in years (I was on beta blockers since '78).

Yes, I'm a "physics gal". Ph.D. early '90s, lost funding due to DoD cutbacks, then made a bad career move and accepted a "permanent" soft money position. I was starting to retrain in medical physics when I got sick in February.

[fizzixgal]

More on abnormal heart rate recovery from CCF...

http://www.clevelandclinic.org/heartcenter/pub/professionals/cardiacconsult/2000/fallwinter2000/abnormheartrate.htm

In case that link gets truncated or mangled, apparently "normal heart rate recovery" was defined as >12 bpm decrease in HR during the first minute after graded exercise.

[Mel22]

Regarding delayed recovery rates, wouldn't that depend on how high you got your heart rate to begin with?

[Momto3]

LOVE your nickname! Beleated congrats on your PhD! What a great accomplishment! There are a number of PhD's who frequent these boards...great way to learn even more! I just finished up my MBA and have pondered a PhD, but first I've got to recover from all that research and writing!

I was on beta blockers from early 80's for about 10-12 years and then off for awhile for a few years. Late 90's was back on for a couple of years. At that time, I was able to take them "as needed." That was ideal! A stress echo in 2000 really demonstrated the efffectiveness of taking even a small dose of BB's. Couldn't get that HR up past about 120 and I was really working. They said the BB blunted the HR from rising (which proved to me that it really worked!)

Strange now because for the first time in my life my resting BP is on the rise. Last two checks were 142/84 and 138/78. Previous to ablations BP was always 100-110/60-70. I go back in August to see what's up with the BP. If it's up, I'm thinking I just may be back in the RX line at the pharmacy...Dr. said it could have something to do with eliminating the ectopics. Now that the extra beats are so far and few between, my heart may be functioning better overall.  Anyone else have rise in BP after ablation?

[netrox]

I always want to know.... if the heart recovery rate is abnormal, is there a way to improve the heart recovery rate?

-jeff

[Intern]

I've wondered, specifically, what Greg Welch's diagnosis was? I was under the impression that he's undergone several surgeries, related to this problem and, certainly, can no longer compete.

On the other hand, Stuart O'Grady had VT for over an hour (HR in the 230's) during a Tour de France stage. His teammates pushed him most of that hour, yet he still recovered and contested that stage's sprint finish and finished tenth. Bobby Julich experienced VT and had an ablation, in 1997. In 1998 he finished 3rd overall, in The Tour de France. Both Stuart and Bobby still compete in the "grand tours" (daily racing for 3 weeks) with very good results. I can`t think of any other sports that would be more demanding.

Alec

[I'mallheart]

i am 28 male and try to exersise also..i take 25mg atenolol for tachy and pvcs..i notive them also more when i exersise,i want to get in good shape again but affraid of exersiseing becasue of this..its also prob anxiety now.
tanks

[fizzixgal]

Thanks Connie, I only wish that degree was still worth something after 10+ years. Understand about recovering from grad school, wish I didn't have to go back into that grind! What you say about your bp makes sense, but I guess we're all different. I was getting borderline high readings (140/80) at the clinic on my worst days before the verapamil cut the ectopics way down.

Alec, I can't imagine anyone pushing through an hour of constant pvcs much less VT, that's just awesome... and pretty crazy. Conditioning makes a big difference in what someone can tolerate. Since O'Grady is still competing, what kind of treatment did he have? I don't have any news about Greg Welch's medical developments after his retirement from competition. If he's actually had surgery (as opposed to ablation) then I assume that something structural eventually turned up.

[Intern]

I`ve never learned what kind of treatment Stuart O'Grady had, but from what I`ve read I don't think it was ablation (and I agree it was pretty crazy to continue racing while experiencing VT), but he`s raced, successfully, for a few years since that episode.

Alec

[Intern]

I`ve never learned what kind of treatment Stuart O'Grady had, but from what I`ve read I don't think it was ablation (and I agree it was pretty crazy to continue racing while experiencing VT), but he`s raced, successfully, for a few years since that episode.

Alec

[va_tony]

Hank,

The docs here tend to be evasive if they are not 100% sure of the answer (& probably rightfully so).  The way you worded the question may provide an out: "in your opinion does PVCs at rest , during or after exercise increase the risk of death in a structurally normal heart?"  The key phrase is "structurally normal heart".  That's a loaded question much like "Can I die if I'm healthy?. The answer is probably no if the heart is truly structurally normal.  But the fact is that even if a heart appears (from echo tests, etc.) to be structurally normal, it does necessarily insure that it is so (there could be a hidden problem). Dr. Lauer's study on post exercise induced ectopies would suggest that if you have 7 PVCs or more a minute, ventricular bigeminy or trigeminy, ventricular couplets or triplets, ventricular tachycardia, or ventricular fibrillation AFTER EXERCISE, your heart likely has a hidden problem. In effect, Lauer has invented a new test to determine whether a heart is "structurally normal" or not, involving a treadmill and the appearance of frequent ectopies post-exercise. Unfortunately, the published paper (which as I pointed out earlier can be obtained from the New England Jounal of Medicine webpage upon registration) does not break down the risk of the various ectopies - - in particular, the risk of dying from having 7 or more PVC's a minute after exercise. I would guess that since PVCs are a more common occurance than the other mentioned ectopies, that would suggest that frequent PVCs (7 or more a minute) contributed substantially to the "prediction" of an increased mortality risk.

Here's an abstract of Lauer's paper from http://ora.ra.cwru.edu/showcase/showcasedetail2004.asp?type=post&id=107 . I have issues with the article Connie suggested.

"Poster Abstract

Background: Exercise-induced ventricular ectopy predicts death in population-based cohorts. We sought to examine the prognostic importance of ventricular ectopy during exercise and during recovery, when reactivation of parasympathetic activity occurs, in a clinical cohort. We hypothesized that ventricular ectopy during recovery predicts death better than ventricular ectopy during exercise. Methods: We followed for 5.3 years 29,244 patients (age 56+11, 70 percent male) referred for symptom-limited exercise testing without heart failure, valve disease, or arrhythmia history. Frequent ventricular ectopy was defined as: > 7 ventricular premature beats per minute, ventricular bigeminy or trigeminy, ventricular couplets or triplets, ventricular tachycardia, or ventricular fibrillation. Results: Frequent ventricular ectopy during exercise only occurred in 945 patients (3 percent), during recovery only in 589 (2 percent), and during both exercise and recovery in 491 (2 percent). There were 1862 deaths. Frequent ventricular ectopy during exercise predicted death (5-year death rates 9 percent vs. 5 percent, hazard ratio 1.8, 95 percent confidence interval 1.5 to 2.1, P<0.001), but frequent ventricular ectopy during recovery was a stronger predictor (11 percent vs. 5 percent, hazard ratio 2.4, 95 percent confidence interval 2.0 to 2.9, P<0.001). After propensity matching frequent ventricular ectopy during recovery predicted death (adjusted hazard ratio 1.5, 95 percent confidence interval 1.1 to 1.9, P=0.003), but frequent ventricular ectopy during exercise did not (adjusted hazard ratio 1.1, 95 percent confidence interval 0.9 to 1.3, P=0.53). Conclusion: Frequent ventricular ectopy during recovery after exercise predicts mortality better than ventricular ectopy only during exercise."

Fizzixgal,

BTW. I'm in physics too (Ph.D. Cornell, early 70's).  Still work in a DoD/Navy lab (NRL in DC) performing R&D in the area of lasers and optics (with military applications).

Best regards to all,

va_tony

[va_tony]

Hank,

I agree. Most here suffering from PVCs have absolutely no reason to worry - - the usual PVCs appear to be harmless (before, during and after exercise).  The Lauer study applied to a very special case of "frequent ectopies" after exercise (which happened to include among the ectopies, frequent PVCs).  Even then the risk over normal mortality was increased about 50% (i.e., 7.5% vs 5% "5-year mortality" risk) for a group of mostly men who were on average 56 years old.

Tony

[va_tony]

Fred,

Sorry I waffled a bit with my last answer. I was hoping to place my earlier answer into proper context so as not to appear alarmist. However, like you, I instinctively feel that PVCs are a warning sign. But I can't find any good studies to support this suspicion.  Can you? That's why I said the usual PVCs "appear" to be harmless.

Even the Lauer study (29,000+ tested) seems to conclude (after correcting for hidden variables) that "frequent ventricular ectopies" before and during exercise do not contribute to the overall 5-year mortality rate.  That, in my book, is reasonable data implying that the "usual" PVCs (less than 7 per minute) before, during and after exercise lead to a relatively harmless prognosis (at least when comparing to the general population).

Yes.  Most people have PVCs. One of the middle slides on http://www.medslides.com/member/Cardiology/Sudden_Cardiac_Death/SCD_2002b.ppt show the statistics.  At age 40, half the population have them daily (most probably don't notice). By age 60, more than 90% of the population have PVCs (with nearly 20% experiencing more than 100/day).  So, yes, I agree this could skew the "normal" mortality rate as reported in Social Security tables. But without evidence to clearly show this, it remains just a suspicion. I always base beliefs on solid experimental data, no matter how reasonable the theory appears (and assuming the experimental study is not flawed).  Unfortunately, clinical studies are difficult to design to completely eliminate hidden variables. Also, the medical community seems to have already concluded that PVCs, in the absence of heart disease, are harmless and so there is no incentive for a study that might challenge this belief.

Best regards,

Tony

[fizzixgal]

Thanks for the link, this is very much apropos my question  about breakdown that Lauer's earlier study did not address. I do suspect you are on the right track in thinking of "frequent ventricular ectopy following exercise" as yet another possible marker (among others) for hidden structural heart disease. Not sure whether it's even relevant to myself though as I also suspect that my history is a giant red flag for some kind of heart disease independent of Lauer's criteria. What really confuses and frustrates me is that even though he hasn't ruled out RV dysplasia, my ep still gives me the green light to exercise. I have not even been able to get in to discuss this with him since my first visit.

BTW I was also in AMO physics (theoretical), maybe we crossed paths at DAMOP without realising it.

[Dr. Erik]

Like Hank said, everyone has PVC's but not everyone knows it. I think that PVC's are a warning that we are more in tune with our hearts than the majority who never know they get PVC's. That's the extent of it in my opinion.

Erik

[va_tony]

Fissixgal,

Sorry to hear that your PVCs are so frequent.  I'm looking foward to the CCF-Dr.'s answer to your question when s/he gets back from San Francisco. Hopefully, your scheduled ablation will resolve your difficulties and you can return to your new field of medical physics.  My problem has been PACs and AFIB but is now under control with Rythmol (at least most of the time).

I'm not too active in the APS anymore although I'm still a member(Fellow) and pay division dues for DAMOP, DLS and DBP. I mostly attend OSA and IEEE LEOS sponsored meetings currently. I'm fairly active in the OSA and am the Editor-in-chief of their Letters journal, OL.

Best wishes,

Tony