Increase in arrhythmias

[WagMore]

Dr.
I have had pac's & pvc's for 8 yrs. beginning when I went into perimenopause. Although I've been on 12.5 mg of atenolol which seemed to help in the beginning (all I could tolerate) I've had a significant increase as read on my Holter this June. The results of the 2 Holters I've had:
2005 Holter results: pac's: 2219, of those 2181 were single, 14 paired beats & 3 runs of superventricular tach. pvc's: 2283, of those 2188 were single, 46 paired beats & 1 run of vent. tach. lasting 3 beats @ a rate of 133 BPM.
2007 Holter: Basic rhythm sinus, HR varying from 42-163. pvc's 3623, 3552 isolated, 36 couplets & 43 bigeminal. pac's 10825, 10342 isolated, 195 couplets &25 bigeminal cycles. 29 runs for a total of 93 beats longest was 4 beats, fastest was 227 bpm.

I'm 53, postmenopausal, overweight & out of shape. I tire easily w/exercise, but assume that's simply because I'm "deconditioned". My echo 2 yrs ago showed & EF of 70%, very minor MVP & LVH. I take Micardis for HBP since then which is supposed to reverse LVH in many cases.
My cardiologist seems to think this is an issue of my being uncomfortable and nothing dangerous, but has doubled the dose to 12.5 twice a day. It's not decreased my irregular beats but has made me feel terrible - very fatigued. He wants me to continue to increase atenolol to 50-100 mgs/day. I'd prefer not to be on them at all. I am constantly worried about my heart.

1. Is having this many arrythmias potentially dangerous?
2. Can the beta-blockers be making it worse?
3. What can I do to find a definitive answer w/o going thru invasive procedures?
4. Can I possibly eliminate / significantly reduce these through a healthy diet, regular exercise, weight loss, stress reduction,& the addition of a cal/mag supplement, fish and flax?  
3. Should I seek a second opinion & should that person be an electrophysiologist?

If you could ease my mind a bit & give me some guidance I'd be extremely appreciative.

[Michael J. McWilliams, M.D.]

You will probably never know what is causing the PVCs, all we can do is speculate.

You asked what could be done to risk stratify you and mentioned a t wave alternans test.  This has not been studied for PVCs and I would not order one clinically.  If you order a test, we have to be prepared to act on the results and I would not act on one in the case of normal or near normal heart PVC case.

1. Can having lots of arrhythmias not only cause cardiomyopathy but then begin a vicous cycle of more arrhythmias caused BY the cardiomyopathy?

in there yes, but you are worrying yourself into a frenzy here.  PVC induced CM is very rare.

2.. If there are reversible cardiomyopathies caused by PVCs ( PAC's too?), HOW do you reverse them?

pvc ablation.

3. I looked up the t wave alternans test. How common are false positives with that test?

it depends on the population being screened.  it is a moot point (or Moo point if you ever watched Friends on NBC) -- the test would not be ordered for this scenario.

4. I looked up flecainide and it sounds like something I'd never want to take.

that is why it is a last resort for people that cannot live with the symptoms.  you are at incredibly low risk now.  Interventions like ablation or flecainide actually increase your risk of complications compared to nothing or a beta blocker.

5.  Would you suggest another echo?

Only if you have now symptoms.

[Momto3]

Although it happens, I've been told the chance of developing pvc-induced cardiomyopathy is rare.  If you have not devloped symptoms and your doctor is not concerned, I wouldn't worry about the CM.  However, just having that many ectopics can be frustrating in and of itself.  Has your doctor mentioned trying another BB or an anti-arrythmic?

In my case, reversing the cardiomyopathy was accomplished with 2 ablations.  Prior to that, I had tried flecainide and rhythmol. They were both great at reducing the ectopic events, but I didn't like the side effects I had when I took them.  It was necessary to get things back in working order so ablation(s) was the next logical step.  I feel very fortunate that my doctor pursued pvc-induced CM when there wasn't much research to suggest it could be what caused the CM.

[WagMore]

Oops...I'm in such a hurry to get this question on, whilst editing I pressed "enter"...let me re-do...

Addendum to my reply:

1. Can having lots of arrhythmias not only cause cardiomyopathy but then begin a vicous cycle of more arrhythmias caused BY the cardiomyopathy?
2.. If there are reversible cardiomyopathies caused by PVCs ( PAC's too?), HOW do you reverse them?
3. I looked up the t wave alternans test. How common are false positives with that test?
4. I looked up flecainide and it sounds like something I'd never want to take.
5.  Would you suggest another echo?

Thanks again.

[WagMore]

Addendum to my reply:
1. If there are reversible cardiomyopathies caused by PVCs ( PAC's too?), HOW do you reverse them?
2. Can having lots of arrhythmias not only cause cardiomyopathy but then begin a vicous cycle of more arrhythmias caused BY
2. I looked up the t wave alternans test. How common are false positives with that test?
3.. I looked up flecainide and it sounds like something I'd never want to take.
4. Would you suggest another echo?

[WagMore]

Thanks for your reply. There are a few things I may not have been clear about...
I've had the arrhythmias for 8 yrs., I did have an echo 8rs. ago and it showed eveything to be basically normal with mild MVP. I was not put on any medication until 2 yrs. ago. I was put on Micardis for HBP and within about one month had the 1st Holter (showing the totals above with a grand total of about 4500 in 24hrs.) and a second echo showing the mild MVP and mild LVH. At that point I was put on the atenolol 12.5 mg which I have been taking for 2 yrs. I noticed an increase in my arrhythmias recently and had another Holter one month ago which showed the increase listed above - to a total now of
14, 448 arrhythmias in 24 hrs. That's when the dr. suggested the increase in atenolol. So I have been on it for 2 yrs, but only 12.5 mg.. I've not had another echo, nor was one suggested, so I don't know if anything has changed. I've not heard of reversible cardiomyopathies caused by PVCs,(does that also include PAC's?), but apparently mine have increased which, now that you bring that up, makes me concerned that my heart may be  worse than it was, due to the increase in arrhythmias over the last 2 yrs.  I've hoped that the Micardis had reversed any LVH over the last 2 yrs., which  I won't know unless I get another echo. Is LVH the same as cardiomyopathy?
You mention a drug flecainide – "flecainide will not reduce your risk but may decrease the number of PVCs." If that decreases the number of PVC's, wouldn't that decrease some risk if more PVC's cause cardiomyopathy? Also, when you refer to "PVC's" are you also meaning PAC's? It was pointed out to me that my PVC's were only slightly increased over two years, but the less dangerous PAC's are the ones that leaped from 2,219 to 10,825. I guess that's good.
What is a T wave alternans test, and finally, is it probable that my MVP is causing my arrhythmias and if not, what? I get the feeling no one really knows in many cases.

Also, I wonder why I should bother with beta blockers at all if they don't decrease the number of pvc's and pacs. If it's just a comfort thing, perhaps I'd just feel better not being on them at all.
Just so you know, I'm really not looking to necessarily do anything at all for these like more or different medications or tests, if you and my dr. really think they are not dangerous. If they are not, I can live with feeling them.

Thanks again for your help. I see by your answers to questions on this forum that you truly undertand how disconcerting this problem is.

[Michael J. McWilliams, M.D.]

Hello,
1. Is having this many arrythmias potentially dangerous?
I am sure that you are aware that there are case reports of reversible cardiomyopathies caused by PVCs.  In your case, it sounds like you are having thousands of PVCs over 8 years and your echo is essentially unchanged.  Statistically people with PVCs have a slightly higher risk of cardiac events, but this was only slightly a higher risk and still did not justify any more treatment than a beta blocker.  From what you have written, I would still consider your risk very low.

2. Can the beta-blockers be making it worse?
I doubt.  The problem is there is often a daily or weekly variation in the number of PVCs.  If you stopped your beta blocker, a decrease in the number of PVCs may only be a chance finding and would not prove they are “causing” PVCs.   I would continue the 25 mg for a couple months and see if your fatigue improves after you been on the beta blocker for a while.

3. What can I do to find a definitive answer w/o going thru invasive procedures?
You could do a T wave alternans test to evaluate your short term (9 months to one year) risk of ventricular arrhythmias. The problem is a non negative result would convene an increased risk, but I am not sure what additional therapies could be offered to further decrease the risk – you wouldn’t qualify for a defibrillator and there is not proof that an ablation would further decrease your risk.  It might just make you worry more.

4. Can I possibly eliminate / significantly reduce these through a healthy diet, regular exercise, weight loss, stress reduction,& the addition of a cal/mag supplement, fish and flax?  
There is no data that anyof the above will decrease your PVCs unless your mag is very low.  Diet, exercise and weight loss is recommended for almost anyone that can tolerate it.  If your doctor is ok with this – yes I would recommend it for your general health, but cannot promise it will affect the number of PVCs.

5. Should I seek a second opinion & should that person be an electrophysiologist?
If you seek a second opinion, I would go to an electrophysiologist.  Simply because they can help assess whether you are a good candidate for other medications like flecainide – flecainide will not reduce your risk but may decrease the number of PVCs. If these are all focal PVCs as seen on a 12 lead EKG and the location is easy to reach, they may be willing to do an ablation.  If you were very symptomatic and had right ventricular outflow tract PVCs, I would consider an ablation is you accepted the 1% risk of major complications of an ablation.  It all depends on the location and your symptoms.

I hope this answers your questions.  Thanks for posting and good luck.