Post Exercise PVCs

[bm38]

I'm a 38 year old male with a 16 or so year history of "noticeable" PVCs.  Originally, they weren't particuarly frequent (maybe a few per hour) but annoying.  My doctor tried beta blockers and a calcium channel blocker, none of which had any effect on my PVCs.  ECGs and an echocardiogram were all normal.  I eventually learned to live with them and came off the meds.  

About a year ago I was experiencing some chest pain so I had a cardiac workup.  I'm a mild asthmatic (well controlled with Advair) and I thought it may be related to that.  A holter, stress test, ECG and echocardiogram all were normal.  Around the same time however, I also noticed that my PVCs seemed to be getting more frequent.  For the past six months, I've noticed they are quite frequent after I exercise.  My exercise tolerance is great.  I'm an active cyclist and don't seem to be limited in any way by the PVCs.  My max heart rate is approximately 195 and an average workout will be 3 to 4 hours with an average heart rate of 150 to 160bpm.  However, my real concern is that I've read some recent information that PVCs post exercise (recovery PVCs) may be indicative of CAD.  I also still have random unexplained chest pain, not always in the same location, but always on the left side of my chest and sometimes radiating into my arm.

My primary care doc and the cardiologist I saw a year ago both think my heart is perfectly fine and suspect the chest pain is likely either related to my asthma or is musculoskeletal in nature.  I'm just looking for some insight into the relationship between PVCs and exercise and whether the PVCs are likely significant or indicative of an underlying issue.  

I'm mildly hypertensive (140/90) and have recently (2 months ago) been prescribed felodipine to control this.  My blood pressure is lower now (120/75) but this hasn't seemed to have any effect on the PVCs (not that I expected it to).  

[runnertom]

Bpm, I don't want to alarm you, but I could have written the same question about my situation, except that I never had chest pain. I have been a long time cycle racer, runner, triathlete since age 25. At age 52 or 53 I started noticing a lot of PVC, mostly because my heart rate monitor would "freeze" when I was having them. They were very predicatable, starting when I hit pulse of 110 and then stopping when I hit 145. Cardio said they quit when you "overdrive the focus".  They seemed to be prominent when I stopped exercise like yours. Fortunately, I don't feel mine.
I had a couple of negative stress tests but I ended up having a cath when I reported some transient shortness of breath at the beginning of a run-first block or two. After that, I could run for hours with no problem. I ended up having a cath which showed significant blockage of LAD and total blockage at the first branch (bifurcation). I was told I would "not be allowed out of the hospital until I had it fixed". I had CABG 5 years ago and have continued to run, ride, etc and the PVCs are essentially gone. The cardiologist claims there is no connection between PVCs and ischemia but I have read different.
  Sidenote on my situation: I had a 64 slice CT scan recently. The report was that the LIMA graft of the LAD is essentially closed off, although I still have no symptoms. Review of the orginal cath showed the blockage to be "not so bad" and should probably not have been bypassed. My collateral circulation is apparently picking up the slack as it was at the time of the cath-highly developed collaterals were clearly shown. I have found a number of studies showing that the LIMA grafts close off almost never except when the original blockage was not very bad.
   In your case, the 64 slice Ct might be a good tool as it is minimally invasive and does a very good job of imaging the coronary arteries. The only hitch is the flow in arteries with a lot of calcium cannot be visualized. As a long time heavy exerciser, I would expect you to have high levels of calcium, but thats another story. Check out this link:
Am J Cardiol 2007;99:743–744

[Cleveland Clinic]

You are correct in that PVC's after the stress portion of an exercise stress test may be related to ischemia, but most of the time they are not.  It is a very non-specific finding that in most cases is not related to ischemia, rather to an irritable focus in the LV that acts up with increased catecholamine levels (exercise, stress, etc).  Given that the likelihood of you having significant coronary artery disease is extremely low, mostly by the fact that you exercise for such long periods of time without any particular symptoms makes it extremely unlikely that the PVC's are ischemia related.  One thing to keep in mind about PVC's is that if they add up to more than 15% of all the heart beats in a 24 hour period, they could lead to weakening of the heart muscle.  The frequency of your PVC's is way below 15% therefore you should not be concerned about that at this point. Consider a long acting beta blocker such as nadolol for better control of your PVC's.  It would also help with your blood pressure control as well, potentially getting you of the calcium channel blocker.