19% PVCs

[IUboy65]

I had PVCs for about ten years before my mechanical aortic valve replacement in 1985 at 41 years of age. My cardiologist told me that the PVCs would probably get worse after surgery, because many times the insertion of a foreign object (i.e., my mechanical valve) fouls up the heart's electrical system even more. To the contrary, my PVCs completely went away after surgery!

In 2002, I moved to a new location, and my new cardiologist started me out with an ECG. He detected light, occasional PVCs, of which I could feel no effect. I moved again in 2011, and had a 24 hour Holter monitor done in April, 2012. All my cardiologist told me was that my PVC rate was 9.7% of total beats, but all asymptomatic, so not to worry. Again, I only occasionally noticed a PVC.

I went to my primary care physician for my regular four month checkup in mid-November 2015, and my pulse rate while sitting in a chair kept fluctuating between 35-40 (using the finger monitor for pulse and blood oxygenation). I made an appointment with my cardiologist for 10 days hence. The finger monitor again showed a pulse rate of 33-38 sitting (but 98% blood oxygenation), but when laying on the examining table with ECG leads strapped to me, my pulse read at 73. The ECG was abnormal, and I was ordered for another Holter monitor.

This one came back as abnormal with 19% multifocal PVCs, with episodes of ventricular couplets, ventricular bigeminy as well as ventricular trigeminy. Yet, the report stated that all episodes were asymptomatic (which I find hard to believe, since last August of 2015 my yearly echocardiogram indicated that my ejection fraction had decreased over the last few years from 62% to 45%).

At any rate, my cardiologist prescribed one daily Diltiazem CD 120mg Caps. What seems strange to me is that Diltiazem is for angina and high blood pressure, but is only an OFF LABEL use for arrhythmias. Hence, I have noticed no change in my PVCs (perhaps even a little worse for these first 25 days on Diltiazem, and especially heavy PVCs when I first try to go to sleep at night), nor has my blood pressure been lowered.

I am considering making an appointment with a different cardiologist to have him do a new ECG, go over my Holter monitor report, and consider a drug specifically for arrhythmias. Any other suggestions, or should a 72 year-old man like myself just let nature take it's course?

Thank you for any advice.

[IUboy65]

I'm not talking about what it "feels" like. I'm reading what the meters tell me, both at home and at my doctor's office. My low pulse rate started in mid-Sept. of 2015. Yet the Holter analysis was said to be abnormal, yet asymptomatic. ??????

[researcher09]

I am confused too.  Hopefully, you can be referred to an electrophysiologist that can explain better what is going on.

[IUboy65]

My HR on a home blood pressure meter usually reads between 40 and 55. On a finger Pulse/Oximeter it is usually around 35-45. I used a blood pressure cuff in a pharmacy today, and my HR was 35 with BP of 116/57. It seems logical to me that PVCs leading to 20% skipped beats would cause a heart rate "count" at least 20% below a normal resting HR -- you can't count what ain't there. Can you? What am I missing? I see my cardiologist again this Friday (3/4/2016), so I will inquire about this again. I have never had my last Holter monitor readings explained. (See third post in this thread.) But I was told not to worry about the pulse reading????)

[researcher09]

My understanding is that PVCs always leads to extra beats.  It may "feel" like a skipped beat because the left ventricle was not completely filled before the beat.  The more important thing to monitor is ejection fraction and to avoid progression into VT.  That would be a path towards heart failure.

[IUboy65]

I am on blood thinners because of a mechanical aortic valve. I have never been overweight (currently 5' 9" @ 160 lbs.) The Diltiazem made my PVCs worse, so I stopped recently. The Diltiazem also had some some adverse effect on my INR readings -- they have been fluctuating between 2.6 - 5.3, where previously, they had been fairly steady at around 3.0. (My preferred range is 2.5 - 3.5). My pulse rate remains around 40, but i am told this is because i am skipping 19,000 beats/day.

[researcher09]

I don't understand the connection of how PVCs would lower your HR measured during normal sinus rhythm.  Or is the technician saying you are never in normal sinus rhythm?  HR would be elevated during VT, I would ask for a detailed explanation of how PVC lowers heart rate.  Perhaps there was a confusion between HR and ejection fraction.

[IUboy65]

I forgot to mention a couple of complications:
1) I have Type II diabetes (but insulin dependent), and my healing time from any invasive surgery is 4-5 times someone without diabetes;
2) I am on a warfarin dose of 12.5 mg/daily, and maintain an INR of 2.8-3.5
I have gone off warfarin (and onto a lovonox bridge) for two very minor surgeries in 2007. After each surgery, my stitches kept popping, and I spent four days straight going to the E.R. to stop the profuse bleeding I was experiencing. So, there is no way I could tolerate an ablation or a pacemaker.
If a calcium channel channel blocker is not appropriate, then would a beta blocker be an option, and which ones. Not asking you to play doctor; just need some ideas to research.

[itdood]

The diabetes might be a risk factor for the PVCs.  If you have a weight problem getting that under control would be a positive step.  Why are you on blood thinners?  

[researcher09]

As far as BB vs CCB, you can try it.  What I would suggest is that you insist on having holter monitoring while trying those meds to make sure that they work without slowing your HR further.  I am not optimistic that BB will do any better than CCB.

DM2 is an important consideration.  However it is not a big factor in whether you can be ablated which is way less invasive than an ICD implant.  Furthermore, numerous recent studies are showing that VT/PVC ablations do much better than ICD-alone patients.  In fact, with successful ablation, you can skip the ICD.  For AF (as an example only since you have PVCs), DM2 patients that have ablations live way better than patients that continue on medication.  There is increased risk, albeit small increase, for blood vessel injury as you state.  That would be if you go to a center that has skills and high procedure volume.  Because you have DM2 and PVC ablation is risky than AF ablations, you will want to go to a center that has skills AND magnetic navigation (soft catheters instead of stiff catheters) which lowers the blood vessel trauma complication risk by 10X.  I believe St. Louis has a couple of centers like that which are experienced with diabetic patients.  Cleveland Clinics too will have that also.

[IUboy65]

So, you don't think there's any immediate danger of 19% skipped beats? And what about Diltiazem being prescribed for arrhythmias -- an off label use? The Diltiazem was supposed to bring down the amount of PVCs, which so far it has not.

Here's the info from my 24 hr. Holter monitor. My cardiologist nor his nurse did not explain anything to me from this report:

Rate Stats: Min. Rate-50; Max. Rate-133; Mean Rate-71

Supraventricular Ectopy; Total-140; Singles-130; Couplets-3; Runs-1 (Fastest:1358; Longest:4)

Ventricular Ectopy: Total-55088; Singles-19754; Couplets-2941; Runs-16 (Fastest:137; Longest-5); R on T: 0

Longest RR: 1.70; No A-Fibs

I've given you the other info in my initial post. I hope you can shed a little light on this for me. Thanks!

[researcher09]

I agree with your skepticism with regards to the calcium channel blocker prescription when you have no SVT or AF.  Because your heart rate is already low, I think any ion channel blocker would also do more harm than good.  I agreed with ithood that your best interest would be better served by an electrophysiologist that has the skills to do PVC mapping and ablations.  I am not sure how active Krannert is with regards to ventricular ablations.  There is always Case Western/Cleveland-Clinic if there are no nearby options.

[itdood]

Maybe you should go see an electro physiologist (EP).  If you can bring down the amount of PVCs you might be able to reverse the ejection fraction.  There is a study that shows this.    I'd also want to understand the root cause of the issue.