Management of Persistent Premature Ventricular Contractions

Assessment and Treatment

For patients on Metoprolol ER 100mg once daily who continue to experience premature ventricular contractions (PVCs), catheter ablation is the recommended next step if the PVCs are symptomatic or associated with declining ventricular function, as recommended by the American College of Cardiology 1
The maximum daily dose of metoprolol succinate is 400mg, and current dosing of Metoprolol ER 100mg once daily is within the recommended range 2

Consider increasing metoprolol dose if the patient is tolerating the current dose well and has no contraindications such as bradycardia, hypotension, or heart block, with gradual titration every 1-2 weeks based on clinical response 2
Oral verapamil can be useful for verapamil-sensitive idiopathic left ventricular tachycardia related to interfascicular reentry 3
Amiodarone may be considered for PVC-induced cardiomyopathy to reduce recurrent arrhythmias and improve symptoms and LV function, as recommended by the American College of Cardiology 1
Catheter ablation is recommended for patients with symptomatic PVCs or declining ventricular function when antiarrhythmic medications are ineffective, not tolerated, or not preferred by the patient, with high success rates for idiopathic PVCs 1, 3

Assess for PVC-induced cardiomyopathy, which may occur with frequent PVCs (usually >15% of total beats) and can be reversible with successful treatment, as recommended by the American College of Cardiology 1
Evaluate for underlying structural heart disease that might be causing or exacerbating PVCs, and consider monitoring for multifocal PVCs, which may be associated with increased cardiovascular risk 4

Assess cardiac function with echocardiography if there is concern for PVC-induced cardiomyopathy, as recommended by the American College of Cardiology 1

Avoid class I sodium channel-blocking antiarrhythmic medications in patients with reduced left ventricular ejection fraction as they may increase mortality, as recommended by the American Heart Association, published in Circulation 4