Prognostic significance of exercise-induced premature ventricular complexes: a systematic review and meta-analysis of observational studies

Abstract

Background Exercise-induced premature ventricular complexes (EI-PVCs) are common during exercise stress tests. Their optimal management and prognostic significance remain uncertain. Aim To perform meta-analysis of observational studies on the prognostic significance of EI-PVCs. Methods A search was conducted on Medline and Embase. Inclusion criteria were observational studies comparing the prognosis of patients with and without EI-PVCs whilst exclusion criteria were studies without confounder adjustment and studies with zero endpoints. Composite endpoints included all-cause mortality, cardiac mortality and cardiovascular events. Relative risk of endpoints were analysed with random effects model. Meta-regression and sensitivity analysis were performed. Results Ten studies were included. In asymptomatic patients who had no clinical evidence of heart disease, EI-PVCs were associated with a pooled risk ratio of 1.82 (95% CI 1.44 to 2.30) of developing adverse cardiovascular events over 16 years. The corresponding pooled RR for patients with symptomatic heart disease was 1.36 (95% CI 1.18 to 1.57) over 5.4 years. Sensitivity analysis: only EI-PVCs on the recovery phase of an exercise test, not during exercise, had adverse prognostic significance.

Management of asymptomatic arrhythmias: a European Heart Rhythm Association (EHRA) consensus document, endorsed by the Heart Failure Association (HFA), Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Cardiac Arrhythmia Society of Southern Africa (CASSA), and Latin America Heart Rhythm Society (LAHRS)

“…141,144 The benefit of anticoagulating patients structural alterations that may be associated with the undesired outcome of major ventricular arrhythmias or sudden death ( Table 5). 151,152 There is no absolute threshold of the number of PVCs that can be used as a cut-off for underlying disease and hence should trigger further investigations. A study in apparently healthy athletes has shown that in those with >2000 PVC per day, there was a 30% risk of finding underlying heart disease.…”

Monomorphic Ventricular Arrhythmias in Athletes

“…In a recent meta-analysis of ten studies evaluating exercise-related PVCs during clinical stress testing, exercise-related PVCs correlated with an increased risk of adverse cardiac events, even in asymptomatic patients without overt cardiovascular disease. [16] Interestingly, the sensitivity analyses found that only PVCs seen during the recovery phase of stress testing were associated with adverse outcomes. Notably, these studies did not focus on athletes.…”

Important tips reflected in our daily practice from the American College of Cardiology Electrophysiology Council report on premature ventricular contractions

“…VPCs originating from the outflow tracts and LV fascicles generally do not lead to fatal arrhythmias. The underlying struc- (23,24). Very rarely, the benign PVCs with short coupling interval possess the risk for VT or VF (1).…”

“…As compared to uniform PVCs, complex PVCs with couplets, triplets, or nonsustained forms, possibly, have a malignant character. Multifocal origins, the increasing number of PVCs with exercise, nonoutflow tract and non-LV fascicular PVCs, PVCs with short coupling intervals or wider PVCs are also carrying a malignant character ( 23 , 24 ). Very rarely, the benign PVCs with short coupling interval possess the risk for VT or VF ( 1 ).…”