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PVCS during and post exercise
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PVCS during and post exercise

I am a 19 yo. male who has suffered from pvc/pacs for two years.  The year before the pvcs started I had panic attacks, but have not had one for the two years that the pvc/pacs have been going on.  
I have moderately high blood pressure and acid reflux (treated with prilosec) besides that I take no medication besides a magnesium pill and A and D vitamins.  I have had a resting ekg, a cardiac event moniter, and an echocardiogram The event moniter showed pvc/pacs. My doctor is not concerned.  All have came back normal so I have no structural heart disease. I do have a few questions though.

1.  In the past five months, I have had two episodes of what feels like runs of palpitations that last about 15-20 seconds with breathlessness.  These have never been recorded on an ekg. My doctor said it was maybe some SVT and was not concerned.  Could this be SVT or possibly idiopathic VT. Does this concern you?

2.  I am in college and am in Army ROTC. I have to do intense physical exercise three days a week.  I generally get pvcs/pacs only a few times a day, but in the last few weeks I have noticed that when I am doing my exercise that my palpitations increase quite a bit.  From 10 a day to 10 in twenty minutes during the exercise. Some of the times I get them in the recovery phase.  I ran cross country (distance running) for three years in high school and never had any problems with palpitations.  I was wondering if this concerned you?  Could it be CPVT ( I have no family history of it)?  Are exercise induced pvcs concerning in structurally normal hearts? What about the recovery pvcs? I have heard they are indicitive of CAD, but I am only 19 and my family does not have heart issues except high bp.  
Any thoughts would help, should I keep up with the exercise or drop out of the program? Thank you
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1766434_tn?1316458250

Dear Terry2424,

Thank you for your query.

1. Both PVCs (Premature Ventricular Contraction) and PACs (premature atrial contraction) can trigger SVT (Supra ventricular Tachycardia) and VT (Ventricular Tachycardia). The run of palpitations that you had could be either one. Unless there is an ECG documentation, it is not possible to say which of the two it is, in retrospect.

Since the event has occurred only twice in five months and has lasted only for a very brief time interval, it will be possible to record it only if you get a loop recorder implanted surgically. The other option is to do a detailed, invasive cardiac electrophysiological study and see if the arrhythmia can be reproduced in the EP (Electrophysiology) lab. However, both these methods are invasive and are needed only if you are really troubled by the Arrhythmia.

2. If you feel that exercise increases the frequency of the ectopic beats, it can be documented very easily by doing a structured exercise treadmill test. If a simultaneous 12-lead recording of the ECG is done, and the PVC/PACs are seen in all the 12 leads, then it will be possible to get valuable information about the source of the PVC (left or right ventricle, approximately where in the ventricle), the timing of the PVC, the coupling interval, monomorphic vs polymorphic, post PVC QRS complex, etc. If there is a run of tachycardia provoked during the study, that will also be helpful. Again, isolated PVCs during exercise or recovery in a structurally normal heart may not mean much.

Without a family history of Catecholaminergic polymorphic VT and without any documented polymorphic VT, CPVT may not be likely. Again, CAD (Coronary Artery Disease) at your age in the absence of angina and any other risk factors is most unlikely.

I would also like to know your current BP. Have the use of beta blockers been suggested to you? It would probably help your BP and also reduce the PVCs/PACs, especially exercise related.

Hope that this information helps and hope that you will get better soon.

Thank you for using MedHelp's "Ask an Expert" Service, where we feature some of world's renowned medical experts in their fields. Millions have benefitted from our service to get personalized advice for them and for their loved ones.

Best Regards,
Dr. Raja Sekhar Varma
15 Comments
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1124887_tn?1313758491
Hello, the doctor will comment your post soon, but just one comment from me (I've been where you are and I know it's terrible to get the premature beats during exercise).

First: Are you even sure they are PVCs? Where it's a little uncommon to get lots of PVCs during exercise, PACs are extremely common with increased adrenaline (and similar substances) especially if you are expecting them and you get somewhat anxious when you exercise. The common variant is to have PVCs at rest and PACs during exercise.

Second: Yes, people with premature beats during exercise tend to, at some point, google their way into info about CPVT (so did I :p). Forget this diagnosis. It's extremely uncommon (about 1:10.000) but it's the perfect thing to be afraid of, because it doesn't show up on any test except for lots of PVCs (and other arrhythmias, atrial fibrillation is common and eventually what is known as bidirectional ventricular tachycardia, a polymorphic VT) on a stress test. From what I understand, the PVCs are remarkably easy to reconstruct during stress test and almost always occur when the heart rate is above 100. If you can, when you are relaxed (and earlier in life) exercise without getting lots of premature beats, you should forget this diagnosis.

CAD: I didn't think this was possible at the age of 19, unless you have congenital anormalities in your coronary arteries, which would probably have caused problems earlier in your life, and chest pain as well.

What I think doctors worry about when they see lots of PVCs during exercise in young men, is that some (usually viral) infection may have affected the circulation, causing increased irritability in the heart. This isn't necessarily dangerous, but if the problem gets worse, you could ask your doctor if it is possible to take some blood tests to examine if you have some kind of disease process affecting the heart (troponine) and maybe a cardiac MRI, but that sounds somewhat dramatic if you just have 10 during 20 minutes ("lots" of PVCs during exercise is 10% or more I think; 15 PVCs per minute at heart rate 150).

If you haven't had a stress test, I think that's a fairly reasonable thing to ask your doctor for. It will possibly show (as it did in my case) nothing, because it's less scary to exercise when you have a doctor next to you.

In my case, the problem was just anxiety during exercise. A small dosage of Pranolol (Inderal, beta blocker) before running, fixed the problem.

Just my two cents here. Take care, and I hope the doctor will answer you soon :)
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Avatar_m_tn
Thanks very much for the post, it really helped.  I am probably going to schedule a stress test with my doctor.  
I was really worried about studies that have shown that pvcs during the recovery phase of exercise were prognostic?

Also, I am worried about the pvc/pacs i get in runs for 15/20 seconds, these ahve never been recorded on a ekg because I only get them every 3 months or so, but they are really bothersome. What could this be and do you think it is dangerous ?
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Avatar_n_tn
I too recently started experiencing PVC's during exercise - or anything I do that speeds up my heartrate (vacuuming didn it this weekend) and while sometimes they will stop immediately - most of the time, they last 3-4 hours afterwards. I ended up in ER a couple weekends ago - my HR was 119 and I was having PVC's every 3 beats. Funny thing though - once Dr came in and said I was fine - they immediately went away and I didnt have another one while in there for 2 more hours.

Im a 38yo female, and Ive always been active. Low end of normal bp, cholesterol low and Im 5'9" 132lbs. It is incredibly frustrating though - I am actually finding myself very depressed since I am anxious constantly that something is wrong and they will happen. I have had a stress test and echo done almost 2 years ago when I was having an occassional PVC - all came back fine. I recently had a 2nd holter done - I didnt feel anything while it was on, and Im going to ask for another stress test and echo since I now have these several hour long runs of PVC's. If all comes back normal I guess Im going to have to find a way to deal with it. Right now Im afraid to move!

I had thryoid issues the last several years but have been in remission from that almost one year. All levels are fine. Im tired of the Dr's telling me Im ok but I dont feel ok. I can barely handle the stress of it anymore. I just wanted to tell you your not alone!
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1124887_tn?1313758491
Hello. Please see doctor's reply which answers most of your questions.

It's fairly uncommon to have high blood pressure at your age, so you should definitely get this examined to see if you have any underlying disease that may cause it. Many of those diseases greatly increase your chance of premature beats; hyperthyroids and excess production of catecholamines (adrenaline, etc) to mention a few.

As the doctor also asked: How high is your blood pressure? And how is it measured? Is the "white coat" effect ruled out?

It seems like the doctor also recommends that you get a stress test done.

Like the doctor told you, it's hard to speculate what your rapid heart rate is caused by. However, it's possible to calculate probability, but I need some more information:

1) How rapid was the heart rate during the event? (roughly, like 100, 150, 200 or 250)
2) In what setting did it happen? What (roughly) was your heart rate before it happened? (saying "at rest" or "during activity" is enough)
3) Was the event preceded by lots of premature beats?
4) Did it start and stop instantly (heart rate from say 60 to 180 and back to 60 in a heartbeat)?
5) Did you do anything to trigger it (like standing up, etc?)
6) Did you experience any of the following:
- Dizziness
- Shortness of breath
- Faiting or near-fainting
- Nausea
- Hard heart beats
- Light heart beats
7) Was the tachycardia regular or irregular? If irregular, was it some kind of pattern in the "madness" (like x-x-xxxx-x-x-xxx--x) or not (x---x--x-----x-x-xx-x---xx---x-x) or (x--x--x-x-x-x-x-x-x-x--x--x--x like the heart rate increased or decreased in "steps")?

If you answer this, my guess will be somewhat more qualified :)
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Avatar_m_tn
TO Dr. Varma:
My blood pressure the last time I checked was at 126/80 so not high at all.  However, I can regularly notice that the systolic pressure is in the 130's and 140's sometimes 150. My dad and grandpa both were on high BP meds at an early age so it would not be unlikely.

1. I am not particularly bothered by the runs of palpitations I experience because they happen so infrequently.  However, I would be concerned about them if they increased my chances of sudden caridac death.  At my age would SVT or VT be more likely?  Is either dangerous? I have heard that idiopathic VT is benign. I am much mroe concerned of possible VT as opposed to SVT
2. I just had a run with Army ROTC this morning and am glad to say that I experienced no palpitations today.  However, I usually do get palpitations during exercise.  It seems to me that you think that this would be benign?  I have a structurally normal heart, very unlikely CAD, no cardiomyopathy, heart failure etc.

Since my pvc/pacs are not incessant and my VT/SVT (?) runs are very rare, I am absolutely able and hoping to just live with it.  The only real thing I am concerned is any increased chances of sudden caridac death.  What is your thoughts on those odds?
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Avatar_m_tn
First off, thank you so much for helping me with this.  You seem to be incredibly well informed.  As per your questions.
High Blood Pressure varies for me from my most recent test 126/80 to the 150's  for systolic presssure.  It would not be uncommon for me since my dad and grandpa have been on medication for it since about my age.  
1.  I have no idea how rapid the heart rate was besides saying that it was definately faster than a normal heart rate.  It lasted for about 15-20 seconds and was very dreadful...I thought I was dying.  I didn't take the heart rate and it has only happened twice.
2.  The first time it happened I was in the library studying for a calculus test and was incredibly stressed.  The second time I was sitting in a computer chair and it happened all of the sudden.  So the first time my heart rate was probably high b/c I was stressed and the second time it was normal proably in the 70's
3.  Hard to say, but both incidents feel like one premature beat, normal beat or two, then another premature beat followed by the run of palpitations.

4. Yes it did start and stop instantly or on its own with no medical intervention
5. Like I said, I was very stressed for one of them, but the second one I wasnt at all
6. Yes. A little bit of lightheadedness, but nothing substantial.  I did not feel like I was going to pass out or anything.  During the run I had many consecutive hard heart beats.  
7. It was one palpitation then a one or a few regular heartbeats followed by another palpitation then the run of whatever its was PAC/PVCS.  
Thanks for the help.
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Avatar_m_tn
My blood pressure the last time I checked was at 126/80 so not high at all.  However, I can regularly notice that the systolic pressure is in the 130's and 140's sometimes 150. My dad and grandpa both were on high BP meds at an early age so it would not be unlikely.

1. I am not particularly bothered by the runs of palpitations I experience because they happen so infrequently.  However, I would be concerned about them if they increased my chances of sudden caridac death.  At my age would SVT or VT be more likely?  Is either dangerous? I have heard that idiopathic VT is benign. I am much mroe concerned of possible VT as opposed to SVT
2. I just had a run with Army ROTC this morning and am glad to say that I experienced no palpitations today.  However, I usually do get palpitations during exercise.  It seems to me that you think that this would be benign?  I have a structurally normal heart, very unlikely CAD, no cardiomyopathy, heart failure etc.

Since my pvc/pacs are not incessant and my VT/SVT (?) runs are very rare, I am absolutely able and hoping to just live with it.  The only real thing I am concerned is any increased chances of sudden caridac death.  What is your thoughts on those odds?
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1766434_tn?1316458250

Dear Terry2424,

Thank you for your reply.

Your palpitations could be either SVT or VT. Both are possible. At your age and given that you have a structurally normal heart, both are likely to be benign. However, without documentation of the actual arrhythmia, prognosis is not likely to be accurate.

Since exercise increases your symptoms usually, why don't you get a formal treadmill test done and evaluate the arrhythmia? Once you know what you are dealing with, it is easier to treat and it will ease your anxieties too.

Sudden cardiac death usually results from malignant VT, VF or rarely asystole. It can happen to almost anybody. While there are certain identifiable risk factors, many a time it is not possible to identify the exact degree of risk.

Certain tests like heart rate variability, abnormal QT dispersion, late potential analysis and microvolt T wave alternans can be done. The problem with most of these tests is that the positive predictive value is low though the negative predictive value is high. Thus, if the test is negative, it is highly unlikely for an event to occur. But a positive test may not mean that there is a high chance of an event either.

My advice to you would be to try and document the run of arrhythmia by a loop recorder. Get a formal and complete ECG treadmill test to study the relationship with exercise.

As regards treatment, try simple measures like reduction of stress, avoidance of tea/coffee/other stimulants, cessation of smoking, control of BP, reduction of salt in the diet, taking adequate amounts of fruits and vegetables in your diet, keeping yourself well hydrated, ensuring normal potassium levels, ensuring at least 6 hours of sound sleep every day, and of course monitored exercise. A trial of beta blockers, if recommended by your treating physician, might also help.

Hope that this information helps and hope that you will get better soon.

Thank you for using MedHelp's "Ask an Expert" Service, where we feature some of world's renowned medical experts in their fields. Millions have benefitted from our service to get personalized advice for them and for their loved ones.

Best Regards,
Dr. Raja Sekhar Varma.
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1124887_tn?1313758491
First, let me just say that I think the doctors on this forum do an excellent job! They provide long, qualified answers and they answer follow ups. That's great!

To your questions, which essentially are answered by dr. Varma (and I won't argue against a physician).

I have had some runs of rapid heart rhythm during exercise when I also had a panic attack (at some point I was afraid of exercise because I got those premature beats) and my cardiologist decided it had to be SVT (atrial tachycardia to be exact) because my holter revealed only PACs (and the stress test revealed one PAC). He also told me that ventricular tachycardia in a structurally normal heart was very unlikely.

That said, I've done some of the tests the doctor refer to, my QT dispersion was analyzed and I think it was so low as it could be, 12 msec I think. That's determined through a simple 12 lead EKG interpreted by a cardiologist. Analysis for late potentials and microvolt TWA is also a simple test, a so-called signal averaged EKG (SAEKG or SAECG in english :p) It takes about 10 minutes at your cardiologist's office. Such tests may predict malignant VT (if the heart chambers are able to create an impulse re-entry because some areas are depolarizing and repolarizing slower than others) but as the doctor told you, quite a lot of us have a positive SAEKG (not sure why) but as you know, very few young people suffer from malignant arrhythmias. Of dangerous conditions that may cause sudden death in young people, most of them would be seen on the tests you've done.

Examples:
Prolonged QT syndrome: Is seen by a cardiologist on EKG
Brugada syndrome: Usually the same as above.
Congenital coronary artery anomalities: Would usually cause chest pain earlier.
WPW with fast conduction: Is seen by a cardiologist on EKG
Hypertrophic cardiomyopathy: Is seen by a cardiologist on echo
CPVT: Very unlikely, stress test can rule out.

The only thing we all should remember is to avoid heavy exercise when we have an infection. I watched some football yesterday, and suddenly one player got cardiac arrest. That really doesn't help easing the anxiety... but his doctor said it happened three times a year in this country for people less than 35 years old (and we are 1,5 million young men and women here) so the odds are low. And luckily he survived.

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Avatar_m_tn
Okay, so we found out what the runs of skipped heart beats are.  Today as I was walking to class i started getting a run and I had my friend drive me to the E.R.  The EKG picked up atrial fibrillation which is still going on right now as I am typing this about 12 hours later.  They released me and gave me 25 mg of a beta blocker.  I have an appointment scheduled for my cardiologist on Monday.  As I stated earlier, I have a structurally normal heart.  I have been all over the internet and have found lots of information on lone atrial fibrillation.  
1. I am 19 and now Im really scared.  Is my prognosis much worse than that of the normal population?
2. Will I still be able to exercise with this?  

Would appreciate any advice.  Will let you know what the cardio says on Monday
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Avatar_f_tn
I'm just a patient, but I'm hoping my experience can bring you some relief of worry until you see your cardiologist Monday.

Like you my "events" occurred infrequently and irregularly; about once a month. Not during exercise but shortly thereafter while just sitting and relaxing. All were short-lived, 10 minutes or so. Finally I had a string that lasted probably 3-4 hours total and were caught in ER to verify.

I was put on a 30 day event monitor from e-Cardio in TX. Neat gadget that transmitted data wirelessly or by phone if needed.

I was started on cardizem to slow the heart rate and coumadin to reduce the clot risk. After the event monitor results Rythmol, an anti-arrhythmic was added. The cardizem (a calcium channel blocker) had to be changed to metoprolol (Toprol) for slowing the heart rate due to my encountering edema. I was then put on a 21 day event monitor from e-Cardio (great company to work with) and did not have any events after the third day of Rythmol. Nor have I had any events I am aware of since then.

Other than the edema from the cardizem I've had absolutely no adverse side effects from the Toprol or the Rythmol. Its been just over a year now since the ER visit and initial event monitor.
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1124887_tn?1313758491
Well, given the fact that you're really afraid of VT, this should be good news to you?

If your adrenaline levels hit the sky, it's not at all uncommon to have runs of A-fib. The somewhat surprising part is that you're still in A-fib 12 hours later. Because atrial fibrillation with rapid ventricular response can feel almost regular (typically it's more irregular the slower the ventricular response (=heart rate) is) it's easy to confuse with SVT (and it's often categorized as an SVT).

Because you are 19 years old, I think your doctors will do what they can to correct this rhythm permanently by ablation. They often use medications to slow the heart in people 60-70 years old, but it should be possible to permanently remove your cause of A-fib.

Just one piece of advice: Act quickly here. Atrial fibrillation will change the atria, making them more likely to uphold the fibrillation, the longer you are in this rhythm. If the fibrillation is still present when you see the cardiologist, at least I would have asked him if he could convert it. If this is done within 48 hours they usually don't have to put you on blood thinning meds first.
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Avatar_m_tn
I went into A-fib at around 8 that morning and came out of it around 1 that night so I was in afib for 17 hours.  I went to the cardiologist on Monday and we took an EKG and I was in normal sinus rythm.  The doctor did not seem concerned at all about it.  He said that there was a scale that they used to determine if someone was a candidate for blood thinners and he said if they were at a 2 or over that they prescribed blood thinners.  He said that since I was 19 and had a structurally normal heart that I was at a zero.  He said I have a benign condition.  I am really confused, what do you think? It seems that some people I talk to say its benign and some are a little concerned. My questions for you are this:
1. I would preferably want to not have to do any medical procedures or be on any medication.  Is the reasoning for these things to reduce symptoms or to actually prevent malignant rythms or strokes?
2. Do you think this is actually is benign?  I have read about lone fibrillation, but also I have read about strokes and from what you have said changes in the atria.  
3. Could stress and worry have actually caused this?  I dont mean brought it out but actually caused this.  
You seem incredibly well informed and I really appreciate your help!
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1124887_tn?1313758491
1. I'm sorry, I can't give you specific advice about this, that's something your physician should do. I can answer generally regarding arrhythmias, but not regarding meds and treatment.

2. AF itself, as long as it's well controlled (so your heart rate isn't on average above 100) is not a dangerous arrhythmia to the heart/ventricles. Unfortunately, the atria don't feel so well during this rhythm. In general, the heart chambers (all 4) need both some, but not too high resistance to pump against, as well as a regulated heart rate. Failure on one of those may lead to either a hypertrophied heart chamber (after sustained high blood pressure) or a dilated chamber (after sustained far too high heart rate). Atrial fibrillation may dilate the chambers (atria) which may predispose for more atrial fibrillation.

3. Atrial fibrillation is often triggered by a perfectly (wrong) timed PAC. People that are afraid of ventricular arrhythmias are often concerned about "early PVCs" (a PVC that falls on the previous T wave) but the same phenomenon can happen in the atria (not sure what the name for it is). Impulses may origin from the pulmonary veins which can fire beat somewhat independent from the rest of the atria, and possibly cause atrial fibrillation. But in order for the fibrillation to sustain for a long time, the atria must have some kind of change to make it possible.

I know atrial fibrillation may happen with high thyroids, excess adrenaline, stimulants, etc.

Maybe the best solution is to trust the cardiologist and let him know if your condition gets worse. If he said it's benign, I would trust that.

Take care :)
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