PART 1

Dear RLR,

I have been reading posts on this forum for a number of months.  I would like to express my gratitude and appreciation for the work you have been doing in helping people cope with their anxiety, panic and arrhythmias.  Regrettably, there very few doctors out there who are willing to take extra time and effort to alleviate the fear and anxiety of patients suffering from PVC’s and PAC’s .

I am a 24 year old male, who is in otherwise relatively good health, who developed PVC after a severe flue in August of 2010. I first noticed my pulse skip a beat after a heavy meal.  Of course, I was concerned to about that incident, to say the least.  I got an appointment with a Cardiologist and ran several diagnostic tests.  My ECG was normal, with the exception of an IRBBB, which my doctor told me is considered to be normal and of no prognostic significance.  My ECHO was normal, and my heart did well on a stress test, no PVC’s, with good exercises tolerance.  My 48 hour Holter showed 530 Premature Ventricular Contractions and 10 Premature Supraventricular Contractions.  I was surprised by the number, as I only felt 5 or 6 of them during that period of time.  I asked my doctor if my symptoms might have been caused by a damage the virus (mild localized myocarditis?) caused to my heart (minor fibrosis) or its neurotoxic effects (damage to the Cardiac branch of the CNS).  The doctor though that I never had myocarditis, and he hypothesized that my ectopic activity was caused by an overactive sympathetic  nervous system (enhanced automaticity).   However, he failed to explain to me as to why my SNS became overactive and what can be done to stabilize it. He even suggested that I always had PVCs and was never aware of them.  However, that’s not true, since I wore a Holter Monitor when I was 20 (had it done when I complained about persistence chess tightness, which turned out to be muscle injury) and it recorded perfect sinus rhythm for 48 hours, no PVCs or PACs.  My doctor didn’t really no what to tell me, so he said that people with PVCs have the same life expectancy as the general population and that I should go home and enjoy life.

I was no satisfied with his answer, nor did I believe that PVCs were innocent.  After some research on the internet, I found several studies that clearly demonstrate that PVC, in ABSENCE of identifiable heart disease, do carry a negative prognosis.  The first study I would like to mention is:

“Prognostic Significance of PVCS and Resting Heart Rate” done by Stanford University Medical Center (Engel, et al.) in 2007.

After analyzing 2-minute ECG strips of  over 45,000 individuals and following them for average of 5.5 years, the study came to a conclusion: “The presence of any PVC on a single ECG
is a powerful predictor of all-cause and cardiovascular mortality. The presence of multiple or complex PVCs was not a significantly better predictor although there was a trend towards worse prognosis
in patients with complex forms. Regression analysis demonstrates that heart rate is a significant and independent predictor of the presence of PVCs. Our findings support the hypothesis that activation of the sympathetic nervous system is an important factor in the genesis of PVCs and ventricular arrhythmias. The presence of elevated heart rate is a significant prognostic factor and the combination
of increased heart rate PVCs dramatically increases mortality.”

In fact the study demonstrated that presence of PVCs doubles your cardiovascular mortality, even if PVCs happen at a low resting heart rate (presumably vegally induced).

The second study I would like to mention is “Relation of Atrial and/or Ventricular Premature Complexes on a Two-Minute Rhythm Strip to the Risk of Sudden Cardiac Death (the Atherosclerosis Risk in Communities [ARIC] Study)” 2011. This study monitored 14,574 subjects with normal ECG for 15 years. After analyzing the data they came to a conclusion:  “Participants with PVC were 2 times as likely to have Sudden Cardiac Death (hazard ratio [HR] 2.09, 95% confidence interval [CI] 1.22 to 3.56) compared to those without PVC. Presence of PAC was not significantly associated with SCD (HR 1.15, 95% CI 0.56 to 2.39). Compared to subjects without PVC and PAC, risk of SCD in subjects with PVC and PAC was significantly increased (HR 6.39, 95% CI 2.58 to 15.84). In conclusion, our study shows that subjects with PVCs are significantly more likely to die from SCD, despite not having any known history of cardiovascular disease. This effect appears to be additive when PACs occur concurrently.” In fact having both PVCs and PACs increases your risk of suffering Sudden Cardiac Death by 600 percent!

And finally the last study: "Premature Ventricular Complexes and the Risk of Incident Stroke: The Atherosclerosis Risk In Communities (ARIC) Study."  It monitored 14,000 people for 15 years, and came to conclusions that: “Frequent PVCs are associated with risk of incident stroke in participants free of hypertension and diabetes. This suggests that PVCs may contribute to atrioventricular remodeling or may be a risk marker for incident stroke, particularly embolic stroke.” Their data demonstrated that people with PVCs, who have no heart disease have double the risk of suffering a stroke, than the ones who don’t.  Also, people who have PVCs and PACs are a lot more likely to develop A-Fib in the future.

The above mentioned studies clearly demonstrate that PVCs are not harmless, even when are found in individuals without structural heart disease. On the contrary, PVC are a significant risk factor for Sudden Cardiac Death and Stroke.  People with PVCs and no heart disease have a significantly higher overall mortality than people without these arrhythmias.   Hopefully, these studies will attract some attention to what once was thought of as ‘benign’ arrhythmias and lead to more research and development of treatments for enhanced abnormal cardiac automaticity.

This is all fine and well, with the exception that the PVC complexes in the studies cited are those which originate from within the heart itself. The type of benign palpitations being experienced by persons on this forum, likely including yourself, do not originate from within the heart at all, but rather occur merely due to inappropriate stimulation of the heart by way of the vagus nerve. The studies mentioned, by contrast, are referencing ectopics which constitute evidence of conduction problems. They are not associated with benign palpitations. I have mentioned before that while benign palpitations can technically represent an ectopic event on ECG, it is not what is normally characterized as PVCs or PACs and their association to pathology.

You are in no danger whatsoever and the events that you are experiencing will not shorten your life by even as much as a second in time. It also must be remembered that medical literature is drafted to a target audience. It is improper to simply read such material and subsequently develop a universality concerning the topic. It's not the case at all and although the advent of the Internet has provided access to such materials, it presupposes that the readers are medical professionals. In other words, your interpretation is that a rose by any other name is still a rose. It's simply not the case here and the association between intra-cardiac events and those related to vagus nerve stimulation does not exist in the manner you portend.  

What people commonly describe as a change in heart rhythm is merely action upon the heart by the parasympathetic nervous system. It is the equivalent of a muscle twitch, except in this instance the muscle happens to be the heart. It does not constitute a PVC or PAC, nor any classic arrhythmia at all. It is a benign palpitation event. Nothing more and the presence of them in persons with significant anxiety and stress will never cause sudden cardiac death or any other cardiac event.

The studies do not indicate what you perceive them to implicate.

Beta-blocker therapy is most commonly used in persons who have already suffered myocardial infarction and by reducing cardiac force together with stabilizing rhythm, the work necessary by the heart to perform its function is reduced. The use of beta-blockers in the attempt to treat vagus nerve-induced palpitation events most often does not provide relief. Beta-blockers do impose a mild anxiolytic effect and it is this characteristic which patients observe that provides modest benefit, if any.

The reason that palpitation events are associated with eating or GI disorders is that the vagus nerve innervates the GI tract as the pneumogastric nerve.

The sympathetic nervous system is the compliment to the parasympathetic nervous system and you can think of them more like the gas pedal and brake system of the overall nervous system network. Sympathetic drives can be enhanced by stress or anxiety significant enough to produce a fight or flight response, to which the body responds by inducing specific physiological change in order to contend with the threat or escape from it. Most persons who experience these changes misinterpret them as symptoms of physical disease, bringing their complaints to their healthcare professional, who most often cannot find anything wrong by virtue of standard diagnostic evaluation.

Benign palpitations are most commonly misinterpreted as a sign that the heart is experiencing difficulty. Once detected, most patients become vigilant to their presence and often fixated upon their presence in variable context, ranging from mild concern to social withdrawal as a result of not being able to trust their heart. It is this premise which tends to prolong the body's response to apprehension or fear that danger is constantly looming. While this characterization does not apply to all persons with palpitations, it does represent the majority. GI problems alone can induce the events by virtue of the pathway mentioned earlier.

The bottom line is that no targeted therapy exists to eradicate benign palpitation events. You can certainly speak to your primary care physician or specialist regarding the use of beta-blockers, but I have to tell you that the results are less than encouraging simply because the events are extra-cardiac in nature and do not respond to blockade.

Again, the studies mentioned are not associated with the actual events you and others on this forum are experiencing. They constitute no risk whatsoever.

Best regards and Good Health

You have an Right Bundle Branch Block, technically considered to be a conduction abnormality. It does not constitute a structural heart abnormality. I said conduction abnormality, not structurally normal hearts. You are equating the term PVC cited in the study with that of benign palpitation events induced by the vagus nerve. There is no association. The persons in the studies have structurally sound hearts but have a history of conduction abnormalities which are producing the PVCs and PACs. Persons on this forum are not experiencing conduction abnormalities as a consequence of vagus nerve-induced palpitation events.


My time is available to assist persons experiencing difficulty due to heart palpitations. I'm not here to discuss differential diagnostics. If you read those articles and you believe that it places you at risk of early death or imminent cardiac event, then there is nothing this forum can provide you.

I'd suggest then that you make preparations with your primary care physician or specialist to preempt the event to whatever extent possible.

I also find this particular presentation to arrive very coincidentally to a recently banned forum member for taking aim with very similar provocation.

If the forum does not provide you with anything of value, then I suggest you seek solace elsewhere. No one on this forum is at any risk of early death as a consequence of benign palpitations. Your interpretation is misdirected and absurd.

Best regards and Good Health

RVV

I just read most of that first study (pretty quickly). Okay, so I might be missing stuff, and I'm not a medic, so take this all with a pinch of salt, but:

a) It seems there was only an ECG to rule out heart disease, heart problems, etc. But that isn't going to be definitive. So it's possible there were systematic differences between the 2 groups in terms of the presence of (yet undetected) heart disease;

b) Not absolutely clear that what sort of regression analysis they did for the presence of PVCs. There were differences between the ECGs of the non-PVC and PVC group.

c) Presence of PVCs was predictive of all cause mortality. Well, that just sounds odd. It would suggest there is some other variable at work here (maybe the presence of stress, for example - which we know is correlated with higher mortality).

d) The age-adjusted risk was 1.39 (I think). Well that's not a lot of extra risk (even if the results are reliable). More extra risk if you smoke, for example.

e) The discussion suggests that the role of PVCs in mortality occurs *after* a heart attack (i.e., survive the attack, but disposition towards PVCs increases the chance of V-Fib). But if you're having a heart attack in the first place, then...

f) Sample seems to have been army veterans. You can't assume that army veterans are representative of the population as a whole.

g) ECG was 10-seconds. You stick me on a ten second ECG, chances are I'm not going to have a PVC. So I end up in the better prognosis group. Yet... well, I have plenty of PVCs. Same with you. You averaged slightly over 10 PVCs an hour. About one every 5 minutes. Chances are, you'd have got through the ECG without having a PVC.

As I say, I'm a non-professional, and know nothing about the medicine, but I do know about the difficulty of isolating all your variables in a study such as this one, and it would seem to me that it's a monumentally difficult task. And you shouldn't mistake correlation for causation.

Your response is fine. I want everyone to be able to scrutinize the data for themselves.

Best regards and Good Health

There is nothing to "freak out" about. The individual making those postings was making associations that were entirely inaccurate and the tone of the comments was clearly one of malicious intent.

There are indeed some fairly disturbed people in this world.

There is not one aspect of those studies even remotely connected to the type of disturbance you and the others here are experiencing and you're in no danger whatsoever. Again, the appearance of this member and the postings came directly on the heels of having to ban someone from the forum for making inappropriate postings.

Best regards and Good Health

To me it doesn't seem like RVV wants to "incite fear and uncertainty", but rather that he has seen something (appearently two medical-statistical studies) that has brought doubt to his mind about the truth of eventual consequenses of benign palpitations.
I think that it certainly is within the frames of this group to post discussions as to what the truth is. And that RLR OF COURSE did right in "leaving these posts to read and judge". (I hope you didn't seriously consider censoring them away ...).

To me the important argument, (as another member also has noted) when reading a bit through the studies, is that statistical coincidence DOES NOT equal a causal relation.

But it is always important to leave your mind open to discuss what truth is.

Hi all

It is at least 2 years since I was on this site. Heck, I remember when RLR was known only by his initials and the forum had to change to escape a huge nasty spam attack.

I have had very bad pvc's for 7 years (started after an op). They have and still do cause me huge anxiety.

In all the years I have researched pvc's and missed beats I have found very little evidence that suggest that they are harmful if you have a structurally normal heart - ie an echocardiogram and ekg show no issues.

Anyone with missed beats should of course get them checked out, but they are likely to be benign. if you have no other symptoms.

Anyway, I just happened to see the OP's post and thought I would respond.

I have seen the veterans study mentioned on several heart forums - it has caused a lot of panic and concern. I read a lot on All Experts and the Med Help forums. On both the cardiologists do not give much credance to the study, instead quoting the many other studies which suggest that benign palpitations in the absence of heart disease or structural defects do not affect mortality. The number you have does not matter either apparently.

This is a response to a question about the Veterans study by a Cleveland Clinic cardiologist:


"There are 3 major studies that have shown increased risk of mortality in patients with PVCs, the Tecumseh study, a subanalysis of the MRFIT study, and a study from the Framingham database.  These trials all suffer from "selection bias" -- the nature of the patients is that they are at increased risk of having coronary artery disease.  Statisticians are able to help us attempt to account for this phenomenon, but the statistical corrections are inadequate.  Furthermore, the patients in these studies are not at all like the majority of the people who use this site -- young, otherwise healthy, with symptomatic PVCs. "

I believe there has been some issues about pvc's when recovering from exercise leading to an increased risk of cardiac events.

Even this was dismmissed by the cardiologist on All Experts as it was a deduction based on older veterans - the conclusions cannot be necessarily applied to the general population.

Be realistic - being overweight, drinking, poor diet, smoking etc are more likely to be greater risk factors. We should address the things we can do something about.

Similarly, if you can't do anything about the pvc's, do something about the anxiety. There are excellent cognitive therapy books available that helped me see my health issues more logically, instead of thinking I was about to drop dead.

Stop Thinking, Start Living - Richard Carllson is a good start.

If pvc's were such a huge contributor to early death, the drug comapnies would be pushing for testing and medication for all of us that suffer from them - they aren't, so that should tell you something.

Sorry to be so long-winded. Apologies to people who messaged me and I didn't reply. As I say I haven't been here for 2 years, just felt compelled to respond to the OP.