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Effect of APCs and VPCs on the Risk of SCD
Abstract & Commentary
By Harold L. Karpman, MD, FACC, FACP, Clinical Professor of Medicine, UCLA School of Medicine. Dr. Karpman serves on the speaker's bureau for Forest Laboratories.
Synopsis: This study concluded that subjects without a known history of any cardiovascular disease who demonstrated ventricular premature complexes on a 2-minute rhythm strip are significantly more likely to die from sudden cardiac death and the effect appears to be additive when atrial premature complexes occur concurrently.
Source: Cheriyath P, et al. 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). Am J Cardiol 2011;107:151-155.
Ventricular tachyarrhythmias are the most common causes of sudden cardiac death (SCD), which is an extremely important public health issue with an estimated global prevalence in the range of 4-5 million deaths per year.1,2 Ventricular premature complexes (VPCs) and atrial premature complexes (APCs) are not uncommon in apparently healthy subjects on routine electrocardiograms. In fact, VPCs are present in more than 6% of the general population and APCs occur in approximately 10%-73% of younger patients and in 21%-100% of elderly patients.3-5 Subjects with VPCs have been considered to be at significantly higher risk for development of ischemic heart disease and death; however, it is quite commonly believed that VPCs and APCs are probably not often associated with a dire outlook when observed to occur in patients without known coronary heart disease (CHD).
Cheriyah and colleagues investigated the prospective relationship between baseline ventricular and supraventricular ectopy and clinical cardiac events including SCD, myocardial infarction, and fatal CHD in a population-based sample of subjects without any history of cardiac disease or stroke. They used public-use data from the Atherosclerosis Risk in Communities (ARIC) study, an ongoing prospective study of the cause and natural history of atherosclerosis funded by the National Heart, Lung, and Blood Institute (NHLBI).6 The study population consisted of 14,574 subjects who were free of CHD and stroke history. Participants who demonstrated the presence of VPCs on a 2-minute rhythm strip were twice as likely to have fatal CHD including SCD when compared to subjects without VPCs. APCs were not associated with a higher risk for SCD; however, the risk of SCD increased more than sixfold when VPCs and APCs occurred together. Therefore, the association of APCs appears to be somewhat additive to the effects of VPCs on SCD.
Although the relationship between ischemic heart disease and VPCs is well-documented,7 current medical practice does not recommend treatment of VPCs in patients without known CHD because of concerns regarding adverse reactions associated with antiarrhythmic medications.8,9 Despite the results of these previously published studies, Cheriyath et al concluded that the presence of any VPC on a 2-minute rhythm strip was associated with a significantly increased risk of SCD and fatal CHD even in middle-aged Americans who did not have a prior history of CHD or stroke. In addition, they noted that the presence of APCs resulted in a negative synergistic effect in patients with VPCs resulting in an increased rate of SCD. It must be recognized that the data from the ARIC report, which formed the basis for their conclusions, was derived from 2-minute rhythm strips in patients followed for only a relatively short period of time (i.e., 3 years). However, before leaping to firm conclusions regarding the danger of isolated VPCs, it must be carefully recognized that the ARIC study included only middle-aged (mean age 49 years) Caucasian men studied over a relatively short period of time and that the study did not adjust for multiple co-variables including potassium and magnesium levels, and/or medications that can affect arrhythmias in either a positive or negative way, and that the study also did not exclude participants with a history of stroke.
Before accepting the conclusions of Cheriyath and colleagues, it should be noted that other studies have not shown an adverse outcome for patients with VPCs.10 Obviously, what is now needed is a large, randomized, carefully controlled trial before concluding that administering potentially harmful drugs to any and all patients who demonstrate a simple PVC on a routine office electrocardiogram is appropriate.
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