Editorial to “Association between ventricular arrhythmia (premature ventricular contractions burden and non-sustained ventricular tachycardia) and cardiovascular events in patients without structural heart disease”

IF 2.2 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS
Wei Sheng Jonathan Ong MBBS, Chi Keong Ching MBBS, FHRS
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The minimal threshold for the development of LV dysfunction is a PVC burden of 10% while a PVC burden of &gt;20% portends a higher risk. Upfront catheter ablation is also indicated in symptomatic patients without structural heart disease when the PVCs are of right ventricular outflow tract or fascicular origin.<span><sup>3</sup></span> Beyond the above select patient groups, however, it remains unclear whether frequent PVCs are associated with cardiovascular events in patients without structural heart disease.</p><p>In this issue of the <i>Journal of Arrhythmia</i>, Ogiso et al. conducted a single-center retrospective study with 6332 patients, stratified by the number of baseline PVCs and the presence or absence of non-sustained ventricular tachycardia (NSVT). The primary endpoint was defined as the incidence of cardiovascular events, including all-cause death, acute coronary syndrome, ischemic stroke, systemic embolism, and hospitalization for heart failure. The authors reported that, over a 3 year follow-up period, the frequency of PVCs was not associated with cardiovascular events while the presence of NSVT was associated with a higher risk of heart failure hospitalization. In the NSVT study population, only one of the five cases of heart failure had a reduced ejection fraction.</p><p>Notably, these results differ from previous studies<span><sup>4, 5</sup></span>; however, this can be explained on more careful examination of key study differences. Prior studies have shown that the decrease in cardiac function, increase in heart failure events, and mortality among patients with frequent PVCs were normally noted beyond 5 years of follow-up.<span><sup>4, 5</sup></span> This suggests that the 3 year follow-up period in the study may have been inadequate to detect these differences. 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引用次数: 0

Abstract

Whether frequent premature ventricular contractions (PVCs) in patients without structural heart disease are of prognostic significance is a subject of debate.1 Once considered to be a benign condition, it is now widely known that it can be causative for tachycardia-induced cardiomyopathy. While only a minority of patients with frequent PVCs (>1000 PVCs/day) develop ventricular dysfunction after 5 years of follow-up,2 catheter ablation is curative for these patients with normalization of cardiac function. The minimal threshold for the development of LV dysfunction is a PVC burden of 10% while a PVC burden of >20% portends a higher risk. Upfront catheter ablation is also indicated in symptomatic patients without structural heart disease when the PVCs are of right ventricular outflow tract or fascicular origin.3 Beyond the above select patient groups, however, it remains unclear whether frequent PVCs are associated with cardiovascular events in patients without structural heart disease.

In this issue of the Journal of Arrhythmia, Ogiso et al. conducted a single-center retrospective study with 6332 patients, stratified by the number of baseline PVCs and the presence or absence of non-sustained ventricular tachycardia (NSVT). The primary endpoint was defined as the incidence of cardiovascular events, including all-cause death, acute coronary syndrome, ischemic stroke, systemic embolism, and hospitalization for heart failure. The authors reported that, over a 3 year follow-up period, the frequency of PVCs was not associated with cardiovascular events while the presence of NSVT was associated with a higher risk of heart failure hospitalization. In the NSVT study population, only one of the five cases of heart failure had a reduced ejection fraction.

Notably, these results differ from previous studies4, 5; however, this can be explained on more careful examination of key study differences. Prior studies have shown that the decrease in cardiac function, increase in heart failure events, and mortality among patients with frequent PVCs were normally noted beyond 5 years of follow-up.4, 5 This suggests that the 3 year follow-up period in the study may have been inadequate to detect these differences. Furthermore, as pointed out by the authors, increased use of medical interventions such as anti-arrhythmic drugs and catheter ablation in patients with a larger number of PVCs and NSVT may have contributed to a better prognosis and outcome.

Ogiso et al. reported that one patient with NSVT and heart failure was later diagnosed with hypertrophic cardiomyopathy. This was not detected at baseline with echocardiography. As frequent PVCs and NSVT may indicate subclinical abnormalities, the authors opined that further investigations, including cardiac magnetic resonance imaging (MRI), may be needed in select patients. This recommendation is in line with the ESC guidelines, which recommend cardiac MRI in patients with inconclusive prior investigations or who have an atypical presentation (older age, right bundle branch block morphology).3 The importance of a thorough diagnostic workup for structural heart disease in patients with frequent PVCs and NSVT cannot be overstated as it can significantly alter management with consequent downstream effects on patient prognosis and outcome.

Finally, limitations in the current study design must be recognized. This was a single-center study conducted in a hospital, which exclusively specializes in cardiovascular medicine. As such, its patient population may have achieved stricter control of their cardiovascular risk factors, were initiated on anti-arrhythmic therapy more readily and sent for catheter ablation expediently when indicated. This is not analogous to the general community population making the study results difficult to apply to the general population at large.

Many questions still remain pertaining to any association between PVCs and NSVT and cardiovascular events in patients without structural heart disease. Additional data, such as the origin of the PVCs and NSVT and PVC morphology, would further enrich the database and enhance our understanding. Likewise, long-term outcome data extending beyond 5 years may offer a clearer insight into any potential association. A multi-center study would also help to strengthen research findings. Future research incorporating these elements will help to fill existing knowledge gaps. Nevertheless, studies of this nature are limited and rare, and this study contributes valuable insights to the field.

Authors declare no conflict of interests for this article.

对“非结构性心脏病患者室性心律失常(室性早搏负担和非持续性室性心动过速)与心血管事件之间的关系”的评论。
无结构性心脏病患者频繁室性早搏是否具有预后意义是一个有争议的话题曾经被认为是一种良性疾病,现在人们普遍知道它可以引起心动过速引起的心肌病。而只有少数频繁室性早搏(>;1000室早/天)的患者在随访5年后出现室性功能障碍,2导管消融对于这些心功能正常化的患者是可以治愈的。发生左室功能障碍的最低阈值是10%的PVC负担,而20%的PVC负担预示着更高的风险。对于有症状的无结构性心脏病患者,当室性早搏位于右心室流出道或束状起源时,也可采用导管消融然而,除了上述选择的患者组之外,目前尚不清楚频繁室性早搏是否与非结构性心脏病患者的心血管事件相关。在这一期的《心律失常杂志》上,Ogiso等人对6332例患者进行了一项单中心回顾性研究,根据基线室性早搏次数和有无非持续性室性心动过速(NSVT)进行分层。主要终点定义为心血管事件的发生率,包括全因死亡、急性冠状动脉综合征、缺血性中风、全身性栓塞和因心力衰竭住院。作者报告说,在3年的随访期间,室性早搏的频率与心血管事件无关,而非svt的存在与心力衰竭住院的高风险相关。在NSVT研究人群中,5例心力衰竭患者中只有1例射血分数降低。值得注意的是,这些结果与以前的研究不同4,5;然而,这可以通过更仔细地检查关键研究差异来解释。先前的研究表明,在频繁发生室性早搏的患者中,心功能下降、心力衰竭事件增加和死亡率通常超过5年的随访。这表明该研究的3年随访期可能不足以发现这些差异。此外,正如作者所指出的那样,在室性早搏和非室室血栓患者中增加使用抗心律失常药物和导管消融等医疗干预措施可能有助于更好的预后和结果。Ogiso等人报道了一名非svt合并心力衰竭的患者后来被诊断为肥厚性心肌病。超声心动图在基线时未检测到这一点。由于频繁的室性早搏和非svt可能表明亚临床异常,作者认为可能需要对特定患者进行进一步的调查,包括心脏磁共振成像(MRI)。这一建议与ESC指南一致,ESC指南建议对先前调查不确定或表现不典型(年龄较大,右束分支阻滞形态)的患者进行心脏MRI检查对于频繁发生室性早搏和非室性心动过速的结构性心脏病患者,彻底的诊断检查的重要性不能被夸大,因为它可以显著地改变治疗,从而对患者的预后和结果产生下游影响。最后,必须认识到当前研究设计的局限性。这是在一家专门从事心血管医学的医院进行的单中心研究。因此,其患者群体可能对心血管危险因素有更严格的控制,更容易开始抗心律失常治疗,并在有指征时方便地进行导管消融。这与一般社区人口不同,因此研究结果难以适用于一般人群。在无结构性心脏病的患者中,室性早搏和非svt与心血管事件之间的关系仍然存在许多问题。额外的数据,如室性早搏和非svt的起源和室性早搏形态,将进一步丰富数据库并增强我们的理解。同样,超过5年的长期结果数据可以更清楚地了解任何潜在的关联。多中心研究也有助于加强研究成果。纳入这些要素的未来研究将有助于填补现有的知识空白。然而,这种性质的研究是有限和罕见的,本研究为该领域提供了有价值的见解。作者声明本文无利益冲突。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
Journal of Arrhythmia
Journal of Arrhythmia CARDIAC & CARDIOVASCULAR SYSTEMS-
CiteScore
2.90
自引率
10.00%
发文量
127
审稿时长
45 weeks
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