very frequent asymptomatic PACs

I am a 26 years old male postgraduate. My PACs was found in the entrance physical exam of the graduate school 3 years ago, when I did not have any noticeable symptoms. After a regular ECG and a UCG (Echo), I was reassured that nothing seemed wrong and I should carry on my life. With some further reading about PACs, I finally calm down and came back to my study in physics. Last year, I felt a bit uncomfortable (still without any clear symptoms) when working hard towards my research project. A ECG indicated my PACs were very frequent. A further Holter test recorded 11931 PACs (out of 113305 beats) in 24h with 18 coupled PACs (most of the PACs occurred when I was awake, especially when I did exercise (like walking fast) or was anxious.). Then I took a UCG (Echo) again, together with a blood test of (AST, CK, CK-MB, LDH and LDH1) and a separate test of the thyroid hormone level. All were fine!

The doctor prescribed propafenone to calm down my PACs (150mg tid). After taking the medication for 3 months, I took another Holter test, which recorded 101 PACs (out of 117977 beats) in 24h. Then I stopped the medication and sadly the PACs came back, very frequently again. So my doctor prescribed metoprolol (12.5mg bid). But the dosage seems not enough. I increase the dosage by myself and found that most of the PACs can be calmed down by a dosage of (50mg bid). I am not sure whether the dosage is safe? With the frequency of 11931 PACs out of 113305 beats, I almost did not feel anything. Is it OK for me just to carry on my life without any medification? My PACs may occur as frequent as every 3 beats when I exercise and after I exercise. Is it safe for me to exercise?

[madjlp]

The generally accepted opinion on PACs and PVCs seems to be that, in the setting of structurally sound heart, you should, if possible, go about your life as best as you're able.  In your case your Dr has elected to treat you with meds - I can't comment on specific meds but it does seem clear that the meds significantly reduce your
PACs - were there side effects with the first drug?  Did your Dr explain to you why he wanted to try drug therapy?  Was he concerned about atrial enlargement due to the high incidence of PACs?  The one thing I can say with certainty is that adjusting dosages on your own, outside the purview of physician instructions, is probably a bad idea.  Esp with a heart med, I personally wouldn't mess with a dosage level to the upside without prior clearance.  As far as safely exercising, have you struggled to exercise due to PACs thusfar?  You refer to your PACs as asymptomatic - if you've exercised without incident and your dr has cleared you then I'd say go for it.  If your PACs continue to increase in frequency as you age or if they start tripling or running together as SVT then you may be a candidate for an electrophysiology study to ablate the focus/focal points that are causing the electrical distrubance.  The good news is that there's a high success rate with EP studies for atrial arrhythmias and atrial arrhythmias are generally considered much less dangerous than ventricular arrhythmias (unless you have WPW or structural heart defects).  Good luck.  

[zzx321]

Thank you for your comments. The first drug, propafenone, was well tolerated by me, although there was a few minor side effects as indicated in the drug instruction. Medications came to be necessary to my doctor's view, due to her concern that my PACs may couple and triple and finally turn into  Atrial Fibrillation. She was concerned about atrial enlargement. I has not tried to exercise after starting to take meds. In fact, I stopped having enough excercise 4-5 years ago, which has made me thinking that the appearance of PACs was due to my lack of exercise. The meds really reduced my PACs when I still took them. But the effect was not well preserved after I stopped the meds, sadly. Furthermore, resently, sometimes I can feel my PACs. I do not know whether it has something to do with the meds or just I has become more sensitive to them perceptionally. Nevertheless, the PACs do not scare me. It is the frequency of them that scares me a lot. I just want to know how many otherwise healthy persons have PACs of the frequency as mine (about 10,000/24h)?

[zzx321]

Sorry. In my last comment, "She was concerned about atrial enlargement." should be
"She was NOT concerned about atrial enlargement."  But I myself am concerned about that, should I?

[Momto3]

I had a long history of frequent PVCs (very, very few PACs).  I was in the 20,000+ per day range for a long time.  Took propanolol on/off for about 12 years.  Eventually, I was able to take it as needed for symptomatic relief.  After years of frequent PVCs, I developed PVC-induced cardiomyopathy, but this is a rare side effect and it was only after many years of PVCs.  I took flecainide, then propafenone, but ultimately, had 2 successful ablations.  

Up until the CM, I was only taking medication for symptomatic relief.  It was not medically necessary.  I've always been told that with a structurally normal heart, medications are not first line treatment.  Rather, reassurance is what I've always heard.  If the patient is symptomatic, a beta blocker is sometimes prescribed.

I agree with the poster above, that you should NOT experiment with dosages.  Talk with your doctor further about her reasons for keeping you on medication.  I don't know the statistics on how ofter frequent PACs result in afib, or other problems.  If you're concerned, a 2nd opinion might also help.

[julesluvsdrew]

When you say you were in the 20,000 range for a "long time"..lol what is a long time?

[madjlp]

Is your Dr a primary care physician or a cardiologist?  If she's not a cardiologist then I'd ask to see one; if she is a cardiologist then maybe a second opinion or just a follow up visit to quantify her concerns more clearly and give yourself a chance to voice your worries which she should be able to address.  

[zzx321]

Thank you very much! She is a cardiologist.

[Momto3]

I would say at least 10 years, possibly more.  It's hard to say.  I started out with PVCs in my late teens/early 20's but at the time I didn't really know what they were.  All I knew was that I had high anxiety and the doctor said, "You have the heartbeat of a 70-year old man."  I wasn't supposed to worry though......hmmmm.

Fast forward to my mid-20's, 2nd pregnancy.  The OB says, "Wait here, we're gonna find out about this once and for all." (I sorta blew him off the first time around when he asked about my heartbeat...not sure why).  The nurse brings in the EKG machine, runs a strip and I'm referred to a cardiologist.  WHAT?!!

Off to he cardio (1982) and I'm told MVP, MR....and PVCs....not to worry.  Have checkups every few years to watch the valve.  Touch base every 3-6 months to check PVCs (more for my benefit) I'm told I can take Inderal for the PVCs, so I take it; it helps.  I'm not worried about them, but the anxious feeling is awful.

Mid 1980's, 3rd pregnancy....still having PVCs, and still taking the Inderal, though I don't think I took it all through the pregnancy, can't really remember.  Still having PVCs, but I'm told not to worry, so I don't.

Over the next 10 years, I'm still having PVCs, but taking Inderal on/off to manage.

Late 1990's - That's it!  I've had it....This can NOT be normal!!  Went to my Internist and he thinks I'm having lots of PVCs, but fears the valve needs repair/replacement!!  Holy heart valve Batman!!  Referred to a new cardio (EP) and tests confirm the valve is OK. Whew!

Early 2000's - still having PVCs, but no idea how many....feels the same as always - a LOT!!  Finally have a Holter report to look at - 22,000 PVCs!!  OK, now I have a number; it's high and it can NOT be normal....Wrong again!  Benign!

2001 - Routine checkup reveals cardiomyopathy and tests all but confirm the PVCs are the cause!!  Two ablations, CM resolved and now I only have scattered PVCs.  I'd say I had them daily for 10-15 years.....

I think I got most of it right....it's been so long : )

[julesluvsdrew]

Wow,It seems like if the docs were more on top of it maybe you wouldnt of had to go through all of that...If you started with  A LOT of pvcs shouldnt they of put you on something to help?Im just saying because look what happend....were you upset that this occured when you did what you were supposed to do,had your checkups ect...

[manny777]

Thank you for all this information momto3, you have helped me understand these pvc's and without you and this forum I think I would be very scared. Today I have only felt about 5 pvc's all day and all this month I had them like maybe about 50 to 80 every day with no anxiety because now I don't pay attention to them.

thanks again and God bless you and heal you all!

[Momto3]

Hi Manny777,

You are over the toughest hurdle!!  I'm so happy to hear that you can get through the day and not pay attention to the PVCs!!  That's awesome!  I know they're there, but so are my freckles : )

[Momto3]

Hi julesluvsdrew!!

Oh, quite to the contrary....I have a wonderful EP who has followed me with a fine tooth comb.  Here's the weird part, I was going to see her once/year for about 3 years, pretty much to check on the valve and to see if the PVCs were still bugging me.

PVC-induced CM is very rare; I think I was my doctor's first case and she is the head of the EP Department at the hospital.  My case was going to be written up for a medical journal, but the quality of my pictures wasn't good enough to include in the report (my doctor said people LOVE good pics). So my claim to fame was shot!  LOL

I took Inderal for somewhere around 12 years, but there were times I wasn't taking it...just got tired of it, and since it was more for symptomatic relief, I sometimes chose to go off of it.  I would have another "storm" and go back on for awhile.  I tried atenolol and after one dose I was shaking all over...Although it works for many people, it's def. not for me!  Back to Inderal...

After the initial shock of being diagnoses with CM, I knew I was very, very lucky.  Many doctors aren't aware of the potential rare connection of frequent PVCs and CM.  The big test was whether the CM would resolve after the ablations.  If not, then I would have been stuck with a diagnosis of idiopathic dilated CM (no known cause) and would be on more medication.  I will be forever grateful to my doctor for going the extra mile : )

Now, about that appointment?  Got a date yet?  LOL

[zzx321]

Hi Momto3! Thank you for so much information.
Is there any connection between your MVP and CM? Did you exercise before the diagnosis of CM? My doctor said I should not exercise intensively, since the frequency of my PACs increases when I exercise. When asked whether moderate workout can be good to me, she murmured. She just doesn't know!

[Momto3]

Hi zzx321,

No connection between the MVP and the CM.  I still have MVP/MR, but the CM has resolved.  Prior to the CM, I have absolutely no restrictions for exercise.  Once diagnosed, I don't really remember being told not to exercise, but because I was sometimes tired (and otherwise busy), I wasn't doing too much anyway.  My doctor may have told me not to do anything strenuous, but I just don't remember and since it didn't really apply, I can't say for sure.  My PVCs did not increase during exercise, and in fact, sometimes they would decrease.  The doctor used to say it would be great if I could run all day....NOT!

[zzx321]

Thank you for your information!

[Tonya730]

Momto3,

Did your PVC's seem to increase after your second pregnancy?  I have never had them, and didnt notice mine until my second pregnancy, and now that I am aware it has been a crazy road. I must say my case is not particularly special I was diagnosed with PVC's a couple weeks ago, but have been feeling them for about 12 months.  On a bad day i get about 6 or 7, but i have found that my potassium level is low when i get them. (Due to ER trips) I hate them and they are incredibley annoying, I am 25 and have two small children so they are incredibly distracting.  I dont get them when I work out, only when i am resting or sedentary.  I have noticed that when i get them, my anxiety about getting them worsens the cycle.  I have had an echo, ekg, blood work (only to reveal low potassium two different times this year) But that seems to be it.  I just need support to try and get them out of my mind!

[upbeat633]

It's quite possible that you notice them while you are resting because you are not distracted by any activity/work.

It may be that you also have them while you are working, but because you are busy, you don't notice the pvcs.

Just a thought, it is that way for me. I get thousands per day but mostly I notice them when I'm not doing much, so I try to keep busy.

Do you have to take potassium tablets to keep your levels up, or does eating a banana work just as well?

[Momto3]

Tonya,

That sounds familiar!  The part where you feel them when you're resting - that is so common!  Crazy, huh?

Has the doctor mentioned a potassium supplement?  Don't take it without talking with your doc, it can cause bigger problems.

Hormonal fluctuations bring them out in a lot of women, so the fact that they showed up around your pregnancy makes sense.  Try not to worry...they're more annoying that significant.  Enjoy the little ones!

[rkmaz]

I have left atrial dilatation associated with very frequent disabilating PAC runs which goes on and on for days,Treadmill Echo otherwise ok.Bouts come more often at night.Any suggestion folks ?