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QUESTION: I am 56 years old and suffer from paroxysmal AF for which I have been prescribed Flecainide. I also have a prolonged QT interval of QTc 464.
I was wondering if you could give me some advice regarding the following:
Are frequent PVCs (one every other beat with runs up to six PVCs in a row) that occur  primarily when standing and moving around but subside when sitting anything to be concerned about?
Could frequent PVCs of this nature be connected to a prolonged QT interval?
The Flecainide is ineffective against the PVCs.
Is there other effective treatment that would reduce the frequency of PVCs without compromising the QT interval?

I do not take anything containing caffeine or alcohol so I don't think these extra beats are caused by diet.
I am waiting to see the cardiologist but my appointment isn't until next spring and the extent and frequency of these missed beats is greatly limiting my life to the extent that I find I am having to keep all activity to a minimum and am usually exhausted by the end of the day.
Any advice you can give me would be greatly appreciated.

June

ANSWER: Hi,

I trained in England and remember how ridiculous it is having to wait that long for an appointment!

Let me try address your questions;


Are frequent PVCs (one every other beat with runs up to six PVCs in a row) that occur  primarily when standing and moving around but subside when sitting anything to be concerned about?

I wonder if these are pac's or pvc's. In the setting of af controlled with flecainide i wonder if you indeed have sinus rhythm with prequent pac's and runs of af. They could possibly be pvc's although i doubt you would get 6 in a row, otherwise that would be non sustained vt, i would think a monitor of some sort to clarify the issue would be useful. In the setting of exercise related symptoms, if resting tests are unhelpful, an exercise ekg and or a holter monitor may be useful and help guide treatment. I think regardless, if you haven't had one an echocardiogram is warranted to rule out structural heart disease. Also given your age and possible risk factors, you maybe should undergo some form of stress testing prior to being on flecainide, you may have had all this done though.

Could frequent PVCs of this nature be connected to a prolonged QT interval? unlikely, its difficult to tell without seeing your ekg, you may have a long QRS leading to long qt, or your machine may be reading it wrong, its best to get an expert set of eyes on it,

The Flecainide is ineffective against the PVCs. - it depends if those are truly pvc's. flecainide can be helpful in some but not all cases. Other drugs can be tried, but by this point you really should be under the care of an electrophysiologist, as other drug options or ablation may be an option at this point depending on the morphology and origin of the beats.

Is there other effective treatment that would reduce the frequency of PVCs without compromising the QT interval? Other drugs or ablation are further options but i would need to know a lot more about your case to answer that.



If i were you i would ask to see an electrophysiologist to manage this further, particularly since your quality of life is clearly affected and to discuss all the options on the table by someone who can review your entire case and give an expert opinion.

---------- FOLLOW-UP ----------

QUESTION: Thankyou so much for your reply to my questions. It is nice to have a quick response especially when I am having to wait so long to see the cardiologist.
I forgot to mention that I had an echo cardiogram and exercise ECG four years ago. No structural abnormalities were found but the ECG revealed PVCs but no arrhythmia and I was told there was no change in the QT interval during exercise.
The ectopic heartbeats I get now are almost constant, which they weren't when I had the earlier tests done and although I asked if it was possible to have the tests repeated I was told that this wasn't necessary as they were only conducted four years ago.
In view of the increase in symptoms do you think it would be advisable to have the tests done again?
Is it possible that an underlying heart defect could have been missed during the previous tests and this may be causing the increase in symptoms?
Could such frequent ectopics lead to the occurrence of a potentially dangerous arrhythmia?

I hope you can give me some helpful advice until I can get to see the cardiologist.

Kind regards,

June

Answer
Hi, http://blog.myheart.net/2014/07/30/pvc-heart-beats-are-they-dangerous/, http://blog.myheart.net/2014/06/29/afib-with-rvr-when-the-heart-races-out-of-con, some related reading you may find of interest,

I wouldn't worry about something having been missed on the previous tests. Any significant underlying heart defect would likely have been caught at that time.

I feel that given an increase in symptoms and an increase in PAC/PVC burden that repeat echocardiography is warranted. A stress test wouldn't necessarily be required in the absence of symptoms such as chest pain or shortness of breath with exertion. The rationale for the repeat in echocardiography is that a decrease in LV function would alter the management strategy. Given what i understand of your situation so far, i would have probably order a holter monitor and an echocardiogram. The holter to diagnose the arrhythmia and to assess the arrhythmic burden, and the echo to assess the LV function. Typically PAC's and PVC's are not likely to lead to the occurrence of life threatening arrhythmia.

Hope that was helpful,

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Mustafa Ahmed MD

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Cardiology, Interventional Cardiology, Cardiac Surgery, Hypertension, Pulmonary Embolism, Structural and Valve Disease

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Board Certification Internal Medicine and Cardiology Interventional and Structural Cardiology

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http://blog.myheart.net

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Multiple Publications In High Quality Peer Reviewed Journals. Internationally Recognized.

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MD from The Royal Victoria University of Manchester, England Medicine, Cardiology, Interventional Cardiology, Research Training - University of Alabama

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