Palpitations and PVCs: Why Worry?
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Published 2024-07-31
www.staging.medscape.com/viewarticle/palpitations-…
-TRANSCRIPT-
Matthew F. Watto, MD: Welcome to The Curbsiders. I'm Dr Matthew Frank Watto, here with America's primary care physician, Dr Paul Nelson Williams. This was a classic podcast episode, where we talked about palpitations with Dr Josh Cooper. Tell me, Paul, what was your favorite take- home point from our conversation?
Paul N. Williams, MD: We talked about premature ventricular contractions (PVCs). We often think of PVCs as a symptom of a sick heart, and not as actually causing cardiac pathology. We see them on an EKG and we think, That's weird. So we check the patient's electrolytes to make sure we're not missing something, then we go on our merry way and assume that we've done the most that we can. Dr Cooper was sharing with us that a PVC burden 10% can actually lead to cardiomyopathy. PVCs are often dismissed in the setting of normal electrolytes and a bare-bones workup, and not thought about further. But they probably warrant investigation by someone who deals with them all the time, whether we're talking ablation or medications or other options. Since our podcast, I've been taking PVCs more seriously than I had up to that point.
Watto: Me too. When I read a Holter report, I look at the PVC burden. If it's 1%, it's not as worrisome as if it's 10%. Dr Cooper told us that the heart beats 100,000 times a day. So, 10% would be 10,000 PVCs a day, and that can be enough to cause cardiomyopathy, which is scary.
Sinus tachycardia is another thing that people tend to write off: Oh, it's just sinus tachycardia. I'm terrified of sinus tachycardia. If I have a patient in clinic with a heart rate of 115 beats/min at rest, I'm worried. Why is their heart rate 115 at rest? Maybe it's because you walked in the room and you're America's primary care physician — just to be in your presence gives them tachycardia. But you need to figure that out. There are so many reasons for that. I don't know about you, Paul, but I do investigate.
Williams: From time to time, I will ask a trainee about a patient's tachycardia, and they will say the patient is always tachycardic. That is the least reassuring thing you could say — it sounds really bad. So I agree with you. It's not unusual to be a little bit tachycardic when you're at the doctor's office or in the presence of greatness. But do your due diligence and make sure you aren't missing some underlying cause.
Watto: Dr Cooper mentioned the common things that can cause tachycardia: anxiety, pain, dehydration, or a medication the patient is taking. You might need to check a TSH to make sure it's not hyperthyroidism. I once diagnosed Graves disease before I even examined the patient because I walked in and the heart rate was 125 at rest and the patient was kind of tremulous. I thought, I bet this person has hyperthyroidism and it ended up being Graves disease.
There's also a diagnosis of exclusion — I don't know that I've ever made it — but it's basically idiopathic inappropriate sinus tachycardia. Depending on how long that goes on, if it's fast enough, it can lead to cardiomyopathy. So, I wouldn't just throw a beta-blocker at that. Investigate it, make sure you're confident about why this tachycardia is happening and is it happening outside your office? If so, it might be worth sending them to cardiology.
Let's say you are working up a patient who came in with palpitations. If you find PVCs, that's probably what the patient is feeling. Or maybe you find sinus tachycardia. But what if you find nothing? What do we do then?
Williams: I really liked Dr Cooper's framing of this. Their symptoms mean that something is going on. You can have a conversation saying that you've done a very thorough cardiac workup, and you are fairly certain that the symptoms are not coming from their heart, and that's good news. That means their heart, at least, is not going to kill them.
Transcript in its entirety can be found by clicking here: www.staging.medscape.com/viewarticle/palpitations-…