There are a lot of ways people refer to ventricular premature beats (VPBs) or contractions (PVCs). They may be described as a skipped beat, or a flutter, a hiccup, or even a palpitation. While palpitations can sometimes just be a sensation of a rapid heartbeat, often they are ventricular premature contractions, particularly when they are intermittent. Not everyone who has PVCs needs to see a cardiologist, or has a serious health problem, but some do and those are the ones underwriters look at most carefully.
A physician can easily spot a PVC on an electrocardiogram—since the beat initiates in a different part of the heart than a normal sinus beat, it has an unusual and unmistakable appearance. Doctors first take a history from the patient, such as when the palpitations or sensations occur, medications the person may be taking, signs of possible heart failure or previous surgery for heart problems, other cardiac risk factors, and if the sensation of syncope (passing out) accompanies the premature beats. The biggest red flags for the doctor include the aforementioned light-headed syncope feeling, palpitations that are worsened by exertion or exercise, known heart disease, or a family history of sudden death. And an EKG is a standard part of the workup, even at a time when there are no symptoms.
When the PVCs are not documented on the doctor visit, extended monitoring is usually the next step. With frequent palpitations, a 24 hour Holter monitor is generally used—like a tape recorder for the heart that is worn and documents when and how often the contractions occur. If the palpitations are infrequent and the doctor is still concerned, 14 to 30 day monitors can also be used. Patients generally write down what they are doing and when they have sensations, and it is paired up and matched to the times on the recorder. The recorder can tell what kind of beats they are and if they are coupled or frequent.
Simple PVCs are infrequent, and may be up to 4-5 per minute or less. The benign ones are generally single beats. They will appear identical on the monitoring strip or EKG. The complex ones are more problemsome. They include patterns (like every other beat or every third beat being a premature), consecutive (PVCs that come one after another are more dangerous), multifocal (they have different shapes meaning they come from different areas) or in runs where they will be consecutive and have more marked symptoms.
When infrequent, they may be common and of little or no significance. Without heart disease or problems with cardiac valves, doctors are more concerned with something that hasn’t been diagnosed. An echocardiogram may be the next part of the workup—disorders of the mitral valve on the left side of the heart (mitral valve prolapse) are a common benign finding. In the absence of cardiac disease and when they are infrequent, PVCs require no treatment and do not have underwriting significance. PVCs become significant when they occur in runs of three or more, occur with known heart disease, are frequent (more than 10/minute), or come from different parts of the heart. Their timing may also be problemsome; a PVC that comes at the end of a completing contraction (called R on T phenomenon) can be very serious.
Underwriters look for frequency and complexity of the PVCs, symptoms and complications (syncope), other underlying cardiac disease, treatment and medications used, and the results of any cardiac evaluation. There are also some positive underwriting considerations—PVCs that decrease during stress or during exercise testing for instance are much more likely to be benign that those who have more PVCs with faster heart rates. Preferred consideration is possible when the PVCs are infrequent and without symptoms or associated heart disease.
Robert Goldstone, MD, FACE, FLMI
MD, FACE, FLMI, board certified internist and endocrinologist, was most recently vice president and chief medical officer for Pacific Life and Pacific Life and Annuity. He has extensive brokerage and life insurance experience, having been medical director at both MetLife Brokerage and Transamerica Occidental Life. Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endocrinology and has written monthly for Broker World since 1991. Goldstone does consulting full or part-time as well as on a fill-in basis for companies who need a medical director/physician. He can be reached by telephone at 949-943-2310. Emaill: firstname.lastname@example.org.