PVCs: extra beats from the lower heart
A PVC, or premature ventricular contraction, is an early heartbeat that starts in the lower chambers. It can feel like a skip, a thump, or a flutter. In a healthy heart, PVCs are common and usually harmless. Here is what causes them, when they matter, and how we treat them.
From Dr. Kenneth Civello, MD, MPH, cardiologist and electrophysiologist
Chest pain, trouble breathing, fainting, or feeling like you are about to faint. Do not drive yourself.
What PVCs are
Your heart has its own timer. A PVC is a beat that fires before the timer is ready.
Each normal beat starts in the upper heart and travels down to the lower chambers, which pump blood to your body. A PVC starts in the lower chambers on its own, a little early. Because it comes early, the heart has not filled, so that beat pushes out less blood. Then the heart pauses. The next beat comes after a longer fill, so it feels stronger.
That is why most people do not feel the PVC itself. They feel the pause, or the strong beat after it. Many people have PVCs and feel nothing at all. PVCs get more common with age.
It is whether your heart is otherwise healthy, how many PVCs you have, and how much they bother you. Those three things decide what we do.
What causes them
Often there is no single cause. The heart cells are simply a little irritable. These can make them more likely.
Stimulants
Caffeine, energy drinks, nicotine, and stimulant drugs. Some cold medicines with decongestants, asthma inhalers, and ADHD medicines can do it too.
Alcohol
Extra beats often show up the night of drinking or the next day.
Poor sleep and stress
Adrenaline makes heart cells more likely to fire early. Untreated sleep apnea can add to it. Sleeping well.
Body chemistry
Low potassium or magnesium, an overactive thyroid, anemia, illness, and not drinking enough fluids.
High blood pressure
Years of high pressure thicken and strain the heart muscle. Lowering your blood pressure.
Heart disease
A past heart attack, a weak or thick heart muscle, or valve disease can cause PVCs. This is why we check the heart itself.
Do not stop a prescribed medicine on your own. Ask us first.
How many is too many
Your PVC burden is the share of all your heartbeats that are PVCs. A heart monitor measures it.
Find your PVC count on your monitor report. It may be listed as PVCs, ventricular ectopy, or VEs. Add the total beats if the report shows it. If not, enter how many days you wore the monitor. Nothing you enter leaves this device.
Why the burden matters
When PVCs make up a large share of your beats for months or years, the lower heart can tire and pump less well. This is called PVC induced cardiomyopathy. It is uncommon when the burden is low. The risk rises when PVCs make up about 10 percent of beats or more. Above about 5 percent, if your PVCs bother you, I may suggest medicine. The good news is that the heart often recovers once the PVCs are treated. So we check your heart's pumping strength when your burden is high, even if you feel fine.
Does my report say more than the count?
Yes. We also look at whether your PVCs all look the same, which suggests one spot is firing. We look for runs of PVCs in a row, and whether they rise or fade with exercise. The count is one piece of the picture.
What tests you may need
The goal is to answer two questions. Is your heart healthy? And how many PVCs do you have?
An ECG
A 10 second tracing in the office. It may catch a PVC and show what it looks like. It also looks for other clues.
A heart monitor
A patch you wear for a day to two weeks. It counts every PVC and measures your burden. It also shows whether your symptoms line up with the PVCs.
A heart ultrasound
An echocardiogram shows how well your heart pumps and checks the valves and muscle.
Blood tests
We may check potassium, magnesium, thyroid, and blood counts.
Sometimes more
An exercise test shows what PVCs do as your heart speeds up. A heart MRI can look for scar in the muscle when other tests raise a question.
Your PVCs come on or get worse with exercise. You feel several beats in a row. You have heart disease or a weak heart. Someone in your family died suddenly at a young age.
How PVCs are treated
We treat PVCs for two reasons: they bother you, or they are weakening your heart. If neither is true, you may not need treatment at all.
Knowing they are harmless is often treatment enough. Many people feel them less once they stop worrying about them.
Cut back on triggers
Keep a short log of when you feel them. Try less alcohol, nicotine, and energy drinks, and better sleep. Cut back on caffeine if it sets yours off.
Treat what feeds them
We correct low potassium or magnesium, treat thyroid problems, and treat sleep apnea and high blood pressure.
Medicine
I usually start with a beta blocker, most often acebutolol. It calms irritable heart cells. If it does not help, a calcium channel blocker such as diltiazem or verapamil is next. If those do not help, a stronger rhythm medicine may. Each has side effects we will go over with you.
Ablation
A thin tube goes through a vein in the leg to the heart. We map the spot where the PVCs start and treat it, so it stops firing. Ablation is an option when medicines do not help, when you would rather not take them, or when PVCs are weakening your heart. We perform PVC ablations. Getting ready for your ablation.
Why ablation works better for some PVCs than others
Ablation works best when the PVCs come from one spot and you have enough of them on the day of the procedure for us to find that spot. Some spots are easy to reach. Others sit deep in the muscle or near important structures. We look at the shape of your PVCs on the ECG to estimate where they start before we recommend it.
PVCs on your watch or pocket ECG
Wearables can catch PVCs. They often do not name them.
Inconclusive results
Frequent PVCs are a common reason a watch ECG says inconclusive. My watch ECG says inconclusive.
Irregular rhythm alerts
The alert is built to find AFib. Frequent extra beats can set it off too. An ECG tells the two apart. Irregular rhythm notifications.
A low heart rate
A PVC may be too weak to feel at the wrist. If every other beat is a PVC, a watch, cuff, or finger clip may show half your true rate. When the watch number is wrong.
Naming PVCs
Some pocket ECGs can label PVCs. On KardiaMobile this takes a paid membership. Choosing a personal ECG.
A watch can show that PVCs are there. It cannot measure your burden. For that, we use a medical heart monitor.
Common questions
Are PVCs dangerous?
In a healthy heart, usually not. They matter more if you have heart disease, a weak heart, fainting, or a very high burden. That is why we check your heart before we tell you not to worry.
Can PVCs turn into AFib?
Generally, no. PVCs start in the lower chambers. AFib starts in the upper chambers. Some people have both, and both can cause a skipping feeling. An ECG tells them apart.
Why do I feel them more at night?
Your heart slows when you rest, which leaves more room for early beats. It is also quieter, so you notice your heartbeat more. Lying on your left side puts your heart closer to your chest wall, so each beat feels stronger.
Do I have to give up coffee?
Often, no. In a 2023 trial, people had more PVCs on coffee days. If coffee clearly sets yours off, cut back. If it does not, you may not need to give it up.
Can I exercise with PVCs?
If your tests show a healthy heart, yes. PVCs that fade as your heart speeds up are a reassuring sign. If your PVCs get worse with exercise, or you feel faint, stop and tell us before you keep going.
What are PACs?
PACs are early beats from the upper chambers. They feel the same as PVCs and are also common. Like PVCs, they are usually harmless in a healthy heart.
Will my PVCs go away?
They often come and go over months or years. Some people have a busy stretch, then few for a long time. If they bother you, we can treat them, even if they are harmless.
This page is general education for my patients. It does not replace advice from your own doctor.
Based on: Al-Khatib SM, et al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. J Am Coll Cardiol. 2018. Cronin EM, et al. 2019 HRS/EHRA/APHRS/LAHRS Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias. Heart Rhythm. 2020. Zeppenfeld K, et al. 2022 ESC Guidelines for the Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. Eur Heart J. 2022. Marcus GM, et al. Acute effects of coffee consumption on health among ambulatory adults. N Engl J Med. 2023.