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Three Part Question

In [patients presenting with premature ventricular complex, but no structural abnormalities] does [beta blocker] reduce [symptom of palpitation and PVC frequency]?

Clinical Scenario

A 50 years old man with good past health presents to A&E with a 10/7 history of paroxysmal palpitation. His hear rate is around 80 bpm, and 12 leads ECG shows one PVC over 10 seconds with symptom. Repeat long lead ECG showed no PVC over 60 seconds at time of symptom free. TnI and CBC LRFT are normal. Private echocardiogram and Holter were performed a few days ago for previous episodes, and revealed pvc but no structural abnormalities. Blood tests including TFT in private were all within normal range. A clinical diagnosis of PVC is made. The patient is asking whether there is any drug to reduce his symptom.

Search Strategy

Pubmed 1974 to 01/2016

((((((((beta blocker[Title/Abstract]) OR atenolol[Title/Abstract]) OR metoprolol[Title/Abstract]) OR propranolol[Title/Abstract]))) AND (((((PVC[Title/Abstract]) OR PVCs[Title/Abstract]) OR VPB[Title/Abstract]) OR VPC[Title/Abstract]) OR VES[Title/Abstract]))) AND english[Language]

Search Outcome

79 papers identified of which 7 were relevant studies.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Krittayaphong R, Bhuripanyo K, Punlee K, Kangkagate C, Chaithiraphan S. 2002 Dec	52 consecutive patients with symptomatic VA	a randomized placebo-controlled study	Severity of symptoms	Severity of symptoms, 24-hour ambulatory monitoring (AECG) and quality of life (QOL) were assessed at baseline and 1 month after atenolol. Atenolol significantly decreased symptom frequency (P =.03), and placebo also significantly decreased symptom frequency (P =.002)	Short observation period (1 month only), not mentioned long time benefit. Placebo improved symptoms to the same extent as atenolol, may reflect so-called placebo effect. not double blinded. The inclusion criteria requires frequent premature ventricular complex (PVC count of 􏰇100 per hour, and the conclusion may not apply to low frequency PVC. The study is on RVOT type of PVC only, while LVOT patient may not benefit from atenolol.
			24-hour ambulatory monitoring (AECG)	Atenolol significantly decreased PVC count (P =.001) and average heart rate (P <.001), whereas placebo had no effect on PVC count (P =.78) or average heart rate (P =.44).
			quality of life (QOL)	Neither atenolol nor placebo had an effect on QOL.
Aronow WS, Wong R, Plasencia G, Landa D, Turbow M. 1980 Long Beach, CA 90822	24 patients with frequent PVCs	A double-blind, randomized study	PVCs count	Frequent PVCs were abolished or reduced by 75% or more in 10 of 12 patients (83%) given acebutolol and in 10 of 12 patients (83%) given propranolol.	No control group Not mention symptomatic relief
Chandraratna PA. 1985	Three centers	double-blind, randomized crossover studies	PVCs count	acebutolol significantly (p less than 0.002 to p less than 0.001) reduced mean total PVCs and complex PVCs. In all measurements, acebutolol was superior to placebo (p less than 0.02 to p less than 0.001) and comparable to propranolol and quinidine.	Not mention symptomatic relief
Stec S, Sikorska A, Zaborska B, Kryński T, Szymot J, Kułakowski P. 2012 Poland	84 consecutive patients	a prospective, crossover, open-label study	PVCs	Short-term treatment with propafenone was more effective than verapamil or metoprolol in suppressing idiopathic PVCs.	No long-term observation. Not double blinded
Krittayaphong R, Bhuripanyo K, Raungratanaamporn O, Sriratanasathavorn C, Punlee K, Kangkagate C, Ch 2000 Thailand	46 consecutive patients	Prospective study	symptom and PVCs count	Atenolol improves symptoms, decreases PVC count from ambulatory monitoring, increases exercise duration and suppresses malignant form of VA during exercise.	Only RVOT PVCs concerned.(same study group with previous one)
Capucci A, Frabetti L, Gubelli S, Boriani G, Marchesini B, Boschi S, Ambrosioni E, Magnani B 1989 Italy	20 patients	double-blind crossover study	PVCs count	the combination of tocainide at 1200 mg and metoprolol 200 mg is well tolerated, efficacious in a high percentage of patients, and superior to single drug therapy in patients with stable PVCs.	No parallel control group No washout phase
Kubac G, Klinke WP, Grace M. 1988	30 patients	Randomized double blind trial	Responders (75% or more reduction of PVCs during 24 h Holter monitoring)	There was no significant difference in suppression of ventricular extrasystoles (sotalol 65%, propranolol 44%), with reduction in ventricular couplets being 99% for sotalol and 49% for propranolol.	No placebo control group

Comment(s)

Despite of shortcomings, most of the studies from various groups support the use of beta blocker in PVCs in terms of relieving symptoms and reducing PVC counts, but large-scale long-term studies are needed to show definitive benefits.

Clinical Bottom Line

Beta blocker can be used to improve symptoms and decreases PVC counts in patients with PVCs, but no structural abnormalities.

References

1. Krittayaphong R, Bhuripanyo K, Punlee K, Kangkagate C, Chaithiraphan S. Effect of atenolol on symptomatic ventricular arrhythmia without structural heart disease: a randomized placebo-controlled study Am Heart J. 2002 Dec;144(6):e10.
2. Aronow WS, Wong R, Plasencia G, Landa D, Turbow M. Effect of acebutolol and propranolol on premature ventricular complexes. Clin Pharmacol Ther. 1980 Jul;28(1):28-31.
3. Chandraratna PA. Comparison of acebutolol with propranolol, quinidine, and placebo: results of three multicenter arrhythmia trials. Am Heart J. 1985 May;109(5 Pt 2):1198-204.
4. Stec S, Sikorska A, Zaborska B, Kryński T, Szymot J, Kułakowski P. Benign symptomatic premature ventricular complexes: short- and long-term efficacy of antiarrhythmic drugs and radiofrequency ablation Kardiol Pol. 2012;70(4):351-8.
5. Krittayaphong R, Bhuripanyo K, Raungratanaamporn O, Sriratanasathavorn C, Punlee K, Kangkagate C, Cheumsuk W, Chaithiraphan S. Effect of atenolol on symptomatic ventricular arrhythmia without structural heart disease: a randomized placebo-controlled study J Med Assoc Thai. 2000 Nov;83 Suppl 2:S124-9.
6. Capucci A, Frabetti L, Gubelli S, Boriani G, Marchesini B, Boschi S, Ambrosioni E, Magnani B Tocainide and metoprolol: an efficacious therapeutic combination in the treatment of premature ventricular beats. Clin Cardiol. 1989 Jun;12(6):322-31.
7. Kubac G, Klinke WP, Grace M. Randomized double blind trial comparing sotalol and propranolol in chronic ventricular arrhythmia. Can J Cardiol. 1988 Oct;4(7):355-9.