In April 2020, the following article was published in Circulation, one of the flagship journals of the American Heart Association and is widely regarded as one of the most influential cardiovascular journals in the world.
Marcus GM. Evaluation and Management of Premature Ventricular Complexes. Circulation. 2020;141(17):1404-1418. doi:10.1161/CIRCULATIONAHA.119.042434.
https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.119.042434
Summary
A Landmark Review by Gregory M. Marcus, MD, MAS (Circulation, 2020)
Premature Ventricular Complexes (PVCs) are among the most common heart rhythm abnormalities encountered in clinical practice. Although many people experience occasional PVCs without even noticing them, others suffer from frequent palpitations, skipped beats, chest discomfort, dizziness, fatigue, and anxiety. In this widely cited review article, Dr. Gregory M. Marcus provides a comprehensive overview of what is currently known about PVCs, including their causes, diagnosis, prognosis, and treatment.
Published in Circulation, one of the world’s most respected cardiology journals, this review is considered an important reference for physicians, cardiologists, electrophysiologists, and researchers involved in the care of patients with ventricular arrhythmias.
Who is Dr. Gregory Marcus?
Dr. Gregory M. Marcus is Professor of Medicine and Director of Clinical Research in the Division of Cardiology at the University of California, San Francisco (UCSF). He is internationally recognized for his research into cardiac arrhythmias, including premature ventricular complexes (PVCs), atrial fibrillation, and sudden cardiac death.
Over the past two decades, Dr. Marcus has authored numerous influential studies examining the prevalence, causes, and long-term consequences of heart rhythm disturbances. His work is frequently cited in international cardiology guidelines and scientific literature.
Because of his extensive contributions to the field, this review article is often regarded as one of the most authoritative summaries of PVCs available to both clinicians and patients.
PVCs Are Extremely Common
One of the key messages of the review is that PVCs are far more common than many people realize.
As monitoring technology has improved, researchers have discovered that PVCs can be detected in the majority of individuals if monitoring is performed for a sufficiently long period. Studies using modern ambulatory ECG devices have shown that occasional PVCs may be present in almost everyone.
The author emphasizes that the presence of PVCs alone does not necessarily indicate serious heart disease.
Why Do PVCs Occur?
The exact reasons why some people develop frequent PVCs remain incompletely understood.
The review describes several possible mechanisms:
- Triggered electrical activity within heart cells
- Increased automaticity of certain cardiac tissues
- Re-entry circuits within the heart’s electrical system
- Influences from the autonomic nervous system
- Effects of catecholamines such as adrenaline
Although significant progress has been made in understanding these mechanisms, the author acknowledges that many fundamental questions remain unanswered.
Common Symptoms
PVCs may be completely asymptomatic, but they can also produce a wide variety of symptoms, including:
- Skipped heartbeats
- Forceful or pounding heartbeats
- Palpitations
- Breathlessness
- Fatigue
- Lightheadedness
- Chest discomfort
Interestingly, the sensation many patients experience is often not the PVC itself, but the stronger heartbeat that follows it.
The review also notes that some individuals may feel only a small percentage of their PVCs, while others are highly sensitive to even occasional ectopic beats.
The Importance of PVC Burden
One of the most important topics discussed is PVC burden, meaning the percentage of total heartbeats represented by PVCs.
While occasional PVCs are generally considered benign, increasing evidence suggests that a high PVC burden may contribute to weakening of the heart muscle in certain individuals. This condition is known as PVC-induced cardiomyopathy.
The review summarizes multiple studies showing that:
- Higher PVC burdens are associated with an increased risk of reduced heart function.
- Many patients improve significantly after successful suppression of PVCs.
- Catheter ablation can sometimes completely reverse PVC-induced cardiomyopathy.
Although no exact threshold applies to every patient, burdens above approximately 10–20% of total heartbeats receive particular attention in clinical practice.
Evaluation and Testing
The author recommends a structured evaluation for patients with frequent or symptomatic PVCs.
Important investigations may include:
- Medical history and physical examination
- 12-lead ECG
- Echocardiogram
- Ambulatory monitoring (Holter monitor or ECG patch)
- Cardiac MRI in selected cases
The goal is not only to measure PVC frequency but also to determine whether any structural heart disease is present.
Lifestyle Factors
The review discusses several lifestyle factors that may influence PVC frequency.
Observational studies suggest associations between PVCs and:
- Smoking
- Higher blood pressure
- Physical inactivity
One particularly interesting conclusion concerns caffeine.
Contrary to popular belief, the author notes that evidence linking caffeine consumption to PVCs remains inconsistent. While some patients clearly notice worsening symptoms with coffee or caffeine, the scientific evidence does not currently support a universal recommendation that all PVC patients avoid caffeine.
Instead, individualized assessment and self-experimentation are encouraged.
This topic was further investigated in his 2023 article Coffee’s effects on cardiac arrhythmias, physical activity, sleep and serum glucose: Insights from the Coffee and Real‐time Atrial and Ventricular Ectopy trial
https://pmc.ncbi.nlm.nih.gov/articles/PMC10374881/
Although coffee has often been considered harmless with regard to cardiac arrhythmias, the CRAVE trial found no increase in PACs but approximately 50% more PVCs on coffee-consumption days. Participants consuming more than one caffeinated coffee per day experienced roughly twice as many PVCs. These findings suggest that coffee may act as a trigger for ventricular ectopy in some individuals and highlight the importance of distinguishing between PACs and PVCs when studying arrhythmia triggers.Marcus GM. Coffee's effects on cardiac arrhythmias, physical activity, sleep and serum glucose: Insights from the Coffee and Real-time Atrial and Ventricular Ectopy trial. Clin Transl Med. 2023 Aug;13(8):e1348. doi: 10.1002/ctm2.1348. PMID: 37501286; PMCID: PMC10374881.
Treatment Options
Many patients require no treatment beyond reassurance.
However, treatment may be appropriate when:
- Symptoms significantly affect quality of life
- PVC burden is high
- Heart function becomes impaired
First-line treatment options include:
Beta Blockers
Medications such as metoprolol, bisoprolol, or nebivolol may reduce symptoms and PVC frequency in some patients.
Calcium Channel Blockers
Verapamil and diltiazem may be useful alternatives, particularly in patients with structurally normal hearts.
Antiarrhythmic Drugs
More potent medications may be considered in selected patients but generally require specialist supervision because of potential side effects.
Catheter Ablation
The review describes catheter ablation as the most effective treatment for eliminating PVCs.
Success rates commonly range between 80% and 95%, particularly when PVCs originate from common locations such as the ventricular outflow tracts.
For many patients with symptomatic PVCs or PVC-induced cardiomyopathy, catheter ablation can provide substantial improvement and, in some cases, complete resolution of symptoms.
Key Takeaway
The central message of this review is reassuring:
Most PVCs are benign and do not indicate a dangerous heart condition.
However, PVCs should not always be dismissed. Frequent PVCs can sometimes contribute to reduced heart function, making proper evaluation important. Modern diagnostic techniques allow physicians to identify patients who may benefit from monitoring, medication, or catheter ablation.
At the same time, the review highlights how much remains unknown about the underlying causes of PVCs and why some people experience debilitating symptoms while others do not.
Editor’s Note
While this review is one of the most respected modern overviews of PVCs, it contains almost no discussion of gastrointestinal influences on cardiac rhythm.
Conditions frequently discussed within the Roemheld Syndrome (Gastrocardiac Syndrome) literature—such as gastric distension, hiatal hernia, reflux disease, vagal nerve stimulation, and post-meal palpitations—are largely absent from the review.
This does nicht mean these mechanisms have been disproven. Rather, they remain under-investigated within mainstream cardiology research.
Interestingly, Dr. Marcus acknowledges that many of the fundamental causes of PVCs remain incompletely understood. This leaves open the possibility that gastrointestinal, autonomic, and vagal influences may contribute to arrhythmias in at least some patients.
For individuals who consistently experience PVCs, PACs, tachycardia, atrial fibrillation, or other palpitations after eating, additional research into the gut–heart connection remains both relevant and necessary.
Update
🆕 We had the pleasure to interview Dr. Marcus on the topic of gastrointestinal triggered PVCs.