Polymorphic extrasystole. Ventricular extrasystole: causes, symptoms, localization of the source of extrasystoles

Description

Ventricular extrasystole

Extrasystoles are those contractions of the heart that occur under the influence of sources other than the sinus node. In the case when “unscheduled” contractions come from fibers located in the ventricles of the heart, this phenomenon is called ventricular extrasystole. When the heart rhythm is disturbed by contractions, the rhythm of which is “set” by the fibers of the atria, this is supraventricular extrasystole. With contractions coming from different parts of the heart, polytopic ventricular extrasystole occurs.

Description:

Ventricular extrasystole is a premature excitation that occurs under the influence of impulses emanating from various parts of the conduction system of the ventricles. The source of ventricular extrasystole in most cases is the branches of the His bundle and Purkinje fibers.

Symptoms of Ventricular extrasystole:

There are no complaints or consist of a feeling of “freezing” or “push” associated with increased post-extrasystolic contraction. Moreover, the presence of subjective sensations and their severity do not depend on the frequency and cause of extrasystoles. With frequent extrasystoles, patients with severe heart disease occasionally experience weakness and dizziness. anginal pain and shortness of breath.

An objective examination occasionally reveals a pronounced presystolic pulsation of the jugular veins, which occurs when the next systole of the right atrium occurs with the tricuspid valve closed due to premature contraction of the ventricles. This pulsation is called Corrigan's venous waves.

The arterial pulse is arrhythmic, with a relatively long pause after the extraordinary pulse wave (the so-called complete compensatory pause, see below). With frequent and group extrasystoles, the impression of atrial fibrillation may be created. In some patients, a pulse deficiency is determined.

During auscultation of the heart, the sonority of the first tone may change due to asynchronous contraction of the ventricles and atria and fluctuations in the duration of the P-Q interval. Extraordinary contractions may also be accompanied by splitting of the second tone.

The main electrocardiographic signs of ventricular extrasystole are:

1.premature extraordinary appearance of an altered ventricular QRS complex on the ECG;

2. significant expansion and deformation of the extrasystolic QRS complex;

3. the location of the RS-T segment and the T wave of the extrasystole is discordant to the direction of the main wave of the QRS complex;

4.absence of P wave before the ventricular extrasystole;

5.the presence in most cases of a complete compensatory pause after a ventricular extrasystole.

The course and prognosis of ventricular extrasystole depend on its form, the presence or absence of organic heart disease and the severity of ventricular myocardial dysfunction. It has been proven that in persons without structural pathology of the cardiovascular system, ventricular extrasystoles, even frequent and complex ones, do not have a significant effect on the prognosis. At the same time, in the presence of organic heart damage, ventricular extrasystoles can significantly increase the risk of sudden cardiac death and overall mortality, initiating persistent ventricular tachycardia and ventricular fibrillation.

Causes of Ventricular extrasystole:

Ventricular extrasystole

What are ventricular extrasystoles?

Ventricular extrasystoles(PVC) are called premature heart contractions associated with the presence of a small lesion located in the ventricles of the heart, which has the ability to independently generate electrical impulses.

In which patients is ventricular extrasystole more common?

Ventricular extrasystole is more often recorded in males and its prevalence increases with age.

A small number of ventricular extrasystoles are common in healthy populations (up to 80%).

A marked increase in the number of ventricular extrasystoles (at least 1000-5000 extrasystoles per day) can be observed in various diseases of the cardiovascular and respiratory systems.

What factors can provoke the occurrence of ventricular extrasystole?

The occurrence of ventricular extrasystole can be facilitated by:

Diseases of the cardiovascular system (arterial hypertension, coronary artery disease, heart failure);
Diseases of the respiratory system;
Electrolyte metabolism disorders (changes in the concentrations of potassium and magnesium in the blood);
Thyroid dysfunction;
Taking certain substances (caffeine, alcohol, amphetamines, cocaine) and smoking;
Certain medications (digoxin, theophylline);
Many patients do not have any provoking factors, in which case the extrasystole is called idiopathic.

What is the significance of ventricular extrasystole?

A small number of ventricular extrasystoles does not affect the prognosis and does not require treatment.

Pathological number of ventricular extrasystoles:

May occur in patients with cardiovascular disease;
May cause other cardiac arrhythmias (if predisposed);
May lead to chronic heart failure in some patients.

What symptoms are characteristic of ventricular extrasystole?

In most cases, extrasystole is asymptomatic.

Some patients complain of freezing (caused by a compensatory pause) or interruptions, “tumbling” of the heart (caused by a stronger heart contraction after an extrasystole).

The presented complaints often contribute to a feeling of anxiety, which in turn stimulates the release of certain biologically active substances (adrenaline), leading to an increase in the number of extrasystoles and the severity of the heartbeat.

What diagnostic measures are appropriate in patients with ventricular extrasystole?

The main tasks when examining patients are:

Registration of extrasystoles on ECG;
Determining the number of extrasystoles and establishing a cause-and-effect relationship between PVCs and the patient’s complaints during ambulatory ECG monitoring;
Exclusion of possible causes of ventricular extrasystole:

Cardiac diseases;
Non-cardiological diseases.

What are the basic principles of treatment for ventricular extrasystole?

Regardless of the causes of ventricular extrasystole, first of all, the doctor is obliged to explain to the patient that it is a PVC. in itself, is not a life-threatening condition. The prognosis in each specific case depends on the presence or absence of other heart diseases. effective treatment of which allows to achieve a decrease in the severity of arrhythmia symptoms, the number of extrasystoles and an increase in life expectancy.

Treatment methods for ventricular extrasystole

Due to the presence of so-called minor psychiatric pathology (primarily anxiety disorder) in many patients with PVCs accompanied by symptoms, consultation with an appropriate specialist may be required.

Currently, there is no data on the beneficial effects of antiarrhythmic drugs (with the exception of beta blockers) on the long-term prognosis in patients with PVCs, and therefore the main indication for antiarrhythmic therapy is the presence of established cause-and-effect relationship between extrasystole and symptoms, with their subjective intolerance. The most optimal means for treating extrasystole are beta blockers. The prescription of other antiarrhythmic drugs, and especially their combinations, is in most cases unjustified, especially in patients with asymptomatic extrasystole.

If antiarrhythmic therapy is ineffective or the patient does not want to receive antiarrhythmic drugs, radiofrequency catheter ablation of the arrhythmogenic focus of ventricular extrasystole is possible. This procedure is highly effective (80-90% effective) and safe in most patients.

In some patients, even in the absence of symptoms, antiarrhythmic drugs or radiofrequency ablation may be necessary. In this case, indications for intervention are determined individually.

Ventricular extrasystoles (VES) are extraordinary contractions of the heart that occur under the influence of premature impulses that originate from the intraventricular conduction system.
Under the influence of an impulse generated in the trunk of the His bundle, its branches, branching branches or Purkinje fibers, the myocardium of one of the ventricles contracts, and then the second ventricle without previous contraction of the atria. This explains the main electrocardiographic signs of PVCs: premature dilated and deformed ventricular complex and the absence of a normal P wave preceding it, indicating atrial contraction.

In this article, we will consider the causes of ventricular extrasystole, its symptoms and signs, and talk about the principles of diagnosis and treatment of this pathology.

Extrasystoles can appear in healthy people after taking stimulants (caffeine, nicotine, alcohol).

Ventricular extrasystole can be observed in healthy people, especially with (Holter-ECG). Functional PVCs are more common in people under 50 years of age. It can be triggered by physical or emotional fatigue, stress, hypothermia or overheating, acute infectious diseases, taking stimulants (caffeine, alcohol, tannin, nicotine) or certain medications.

Functional PVCs are often detected when the activity of the vagus nerve increases. In this case, they are accompanied by a rare pulse, increased salivation, cold wet extremities, and arterial hypotension.

Functional PVCs do not have a pathological course. When the provoking factors are eliminated, they most often go away on their own.

In other cases, ventricular extrasystole is caused by organic heart disease. For its occurrence, even against the background of heart disease, additional exposure to toxic, mechanical or autonomic factors is often required.

Often PVCs accompany chronic ischemic heart disease (). With daily ECG monitoring, they occur in almost 100% of such patients. Arterial hypertension, heart defects, heart failure and myocardial infarction are also often accompanied by ventricular extrasystole.

This symptom is observed in patients with chronic lung diseases, rheumatism. Extrasystole of reflex origin occurs, associated with diseases of the abdominal organs: cholecystitis, gastric and duodenal ulcers, pancreatitis, colitis.
Another common cause of ventricular extrasystole is a metabolic disorder in the myocardium, especially associated with the loss of potassium by cells. These diseases include pheochromocytoma (a hormone-producing tumor of the adrenal gland) and hyperthyroidism. PVCs can occur in the third trimester of pregnancy.

Drugs that can cause ventricular arrhythmias include primarily cardiac glycosides. They also occur when using sympathomimetics, tricyclic antidepressants, quinidine, and anesthetics.

Most often, PVCs are recorded in patients who have serious changes at rest: signs, myocardial ischemia, rhythm and conduction disturbances. The frequency of this symptom increases with age and is more common in men.

Clinical signs

With a certain degree of convention, we can talk about different symptoms for functional and “organic” PVCs. Extrasystoles in the absence of severe heart disease are usually single, but are poorly tolerated by patients. They may be accompanied by a feeling of freezing, interruptions in heart function, and isolated strong beats in the chest. These extrasystoles often appear at rest, in a lying position, or during emotional stress. Physical tension or even a simple transition from a horizontal to a vertical position leads to their disappearance. They often occur against the background of a rare pulse (bradycardia).

Organic PVCs are often multiple, but patients usually do not notice them. They appear during physical activity and go away with rest, in a lying position. In many cases, such PVCs are accompanied by rapid heartbeat (tachycardia).

Diagnostics

The main methods of instrumental diagnosis of ventricular extrasystole are ECG at rest and 24-hour Holter ECG monitoring.

Signs of PVC on ECG:

premature dilated and deformed ventricular complex;
discordance (multidirectionality) of the ST segment and T wave of the extrasystole and the main wave of the QRS complex;
absence of a P wave in front of the VES;
the presence of a complete compensatory pause (not always).

Interpolated PVCs are distinguished, in which the extrasystolic complex is inserted, as it were, between two normal contractions without a compensatory pause.

If PVCs come from the same pathological focus and have the same shape, they are called monomorphic. Polymorphic PVCs emanating from different ectopic foci have different shapes and different coupling intervals (the distance from the previous contraction to the R wave of the extrasystole). Polymorphic PVCs are associated with severe cardiac damage and a more serious prognosis.
Early PVCs (“R to T”) are classified into a separate group. The criterion for prematurity is the shortening of the interval between the end of the T wave of sinus contraction and the beginning of the extrasystole complex. There are also late PVCs that occur at the end of diastole, which may be preceded by a normal sinus P wave, superimposed on the beginning of the extrasystolic complex.

VES can be single, paired or group. Quite often they form episodes of allorhythmia: bigeminy, trigeminy, quadrigeminy. With bigeminy, a VES is recorded through every normal sinus complex; with trigeminy, a VES is recorded every third complex, and so on.

During daily ECG monitoring, the number and morphology of extrasystoles, their distribution during the day, and dependence on load, sleep, and medication are specified. This important information helps determine the prognosis, clarify the diagnosis and prescribe treatment.

The most dangerous in terms of prognosis are considered to be frequent, polymorphic and polytopic, paired and group VES, as well as early extrasystoles.

The differential diagnosis of ventricular extrasystoles is carried out with supraventricular extrasystoles, complete block of the bundle branches, and escaped ventricular contractions.

If ventricular extrasystole is detected, the patient should be examined by a cardiologist. Additionally, general and biochemical blood tests, an electrocardiographic test with dosed physical activity, and echocardiography may be prescribed.

Treatment

Treatment of ventricular extrasystole depends on its causes. For functional PVCs, it is recommended to normalize the daily routine, reduce the use of stimulants, and reduce emotional stress. A diet enriched with potassium or drugs containing this trace element (Panangin) is prescribed.
For rare extrasystoles, special antiarrhythmic treatment is not prescribed. Herbal sedatives (valerian, motherwort) are prescribed in combination with beta-blockers. In case of JS against the background of vagotonia, sympathomimetics and anticholinergic drugs, for example, Bellataminal, are effective.
If the extrasystoles are organic, treatment depends on the number of extrasystoles. If there are few of them, ethmosin, etacizin or allapinin can be used. The use of these drugs is limited due to the possibility of their arrhythmogenic effects.

If extrasystole occurs in the acute period of myocardial infarction, it can be stopped with lidocaine or trimecaine.

Cordarone (amiodarone) is currently considered the main drug for suppressing ventricular extrasystole. It is prescribed according to a scheme with a gradual reduction in dosage. When treating with cordarone, it is necessary to periodically monitor the function of the liver, thyroid gland, external respiration and the level of electrolytes in the blood, as well as undergo an examination by an ophthalmologist.

In some cases, persistent ventricular premature beats from a known ectopic focus are well treated with radiofrequency ablation surgery. During such an intervention, cells that produce pathological impulses are destroyed.

The presence of ventricular extrasystole, especially its severe forms, worsens the prognosis in people with organic heart disease. On the other hand, functional VES most often do not affect the quality of life and prognosis of patients.

Video course “Everyone can do an ECG”, lesson 4 - “Heart rhythm disturbances: sinus arrhythmias, extrasystole” (VES - from 20:14)

Extraordinary contractions of the heart are called extrasystole. Depending on the location of the source of excitation, several forms of pathology are distinguished. Ventricular extrasystole is considered clinically unfavorable; what it is will be discussed in detail.

Cardiovascular diseases are among the top five diseases that lead to human disability. Extrasystole is the most popular, as it occurs in 70% of people. It can be detected at any age; there is also no connection between the pathology and gender and constitutional characteristics.

Predisposing factors for the development of extrasystole include arterial hypertension, coronary heart disease, heart defects, lack of potassium and magnesium in the blood, as well as gender and age.

Extrasystoles are usually divided into two large groups: atrial and ventricular. The second type is characterized by an unfavorable clinical course, so it is worth knowing why ventricular extrasystole is dangerous and what treatment options are offered by modern medicine.

Description of ventricular extrasystole

The term “ventricular extrasystole” (VES) refers to a pathological process occurring in the left or right ventricle and causing premature contraction of the corresponding parts of the heart.

There are three mechanisms for the development of the disease: violation of automaticity, trigger activity, circular passage of a wave of excitation (re-entry).

Violation of automaticity carried out in the direction of increasing heart rate. This is due to the subthreshold potential of the pathological focus located in the ventricles. Under the influence of a normal rhythm, it transitions to a threshold rhythm, resulting in premature contraction. A similar development mechanism is typical for arrhythmias developing against the background of myocardial ischemia, electrolyte dysfunctions, and excess amounts of catecholamines.

Trigger activity - represents the occurrence of an extraordinary impulse under the influence of post-depolarization, which is associated with the previous action potential. There are early (formed during repolarization) and late (formed after repolarization) trigger activity. It is associated with those extrasystoles that appear during bradycardia, myocardial ischemia, electrolyte disorders, and intoxication with certain drugs (for example, digitalis).

Circular passage of the excitation wave (re-entry) is formed during various organic disorders, when the myocardium becomes heterogeneous, which interferes with the normal passage of the impulse. In the area of scar or ischemia, areas with unequal conductive and restorative rates are formed. As a result, both single ventricular extrasystoles and paroxysmal attacks of tachycardia appear.

Symptoms of ventricular extrasystole

In most cases there are no complaints. To a lesser extent, the following symptoms occur:

uneven heartbeat;
weakness and dizziness;
lack of air;
chest pain is located in an atypical location;
the pulsation can be very pronounced and therefore felt by the patient.

The occurrence of the latter symptom complex is associated with an increase in the force of contraction that appears after extrasystole. Therefore, it is not felt as an extraordinary contraction, but rather in the form of a “fading heart.” Some symptoms of ventricular extrasystole are caused by the underlying pathology that caused the development of the rhythm disturbance.

Corrigan's venous waves- pathological pulsation that occurs with premature contraction of the ventricles against the background of a closed tricuspid valve and right atrium systole. It manifests itself as pulsation of the neck veins, which is so pronounced that it can be noticed during an objective examination of the patient.

When measuring blood pressure, arrhythmic cardiac activity is determined. In some cases, a pulse deficit is established. Sometimes extrasystoles occur so often that an erroneous diagnosis may be made.

Causes of ventricular extrasystole

Non-cardiac and cardiac factors in the occurrence of pathology are considered.

Non-cardiac causes associated more with electrolyte disorders, often occurring during a lack of potassium, magnesium and excess calcium concentration in the blood. The latter disorder is largely associated with malignant processes occurring in the skeletal system, hyperparathyroidism, Paget's disease, and treatment with calcium preparations (which is observed in the treatment of peptic ulcers).

Stressful situations, unhealthy diet, disruption of sleep and rest patterns, and intake of harmful substances (toxic, alcohol, drugs) have a negative impact on the cardiac system. Sometimes after surgery, anesthesia or hypoxia, ventricular extrasystole also develops.

Cardiac factors associated with various pathological conditions of the cardiovascular system. First of all, the ventricular myocardium suffers during heart attacks and ischemic heart disease. Heart defects (mitral valve prolapse), cardiomyopathies and myocarditis have a negative effect on the structure of muscle tissue. Against the background of a slow and rapid heart rate, extraordinary contractions of the ventricles often occur.

Types of ventricular extrasystole

During the study of ventricular extrasystole as a pathology, various classifications and characteristics were created. Based on these, diagnoses are made and subsequent treatment is carried out.

Single and polytopic ventricular extrasystoles

Extrasystoles formed by premature ventricular contractions differ in their characteristics:

the frequency of display on the ECG divides extrasystoles into single, multiple, paired and group;
the time of occurrence of extrasystoles can characterize them as early, late and interpolated;
the number of pathological foci varies, therefore polytopic (more than 15 times per minute) and monotopic extrasystoles are distinguished;
orderliness of extrasystoles is considered in the case of their uniform presence on the ECG; disordered extrasystoles also occur.

The course of ventricular extrasystole

In most cases, benign PVCs occur. If they are present, organic changes are not detected in the heart, the patient may not have any complaints or they are insignificant. In this case, the prognosis is favorable, so you should not worry about whether this disease, ventricular extrasystole, is dangerous.

With potentially malignant ventricular extrasystole, organic changes in the structure of the heart are determined. Most of them are associated with cardiac pathology - heart attack, ischemic heart disease, cardiomyopathies. In this case, the likelihood of premature cessation of cardiac activity increases.

The malignant course of ventricular extrasystole is extremely dangerous for the patient’s life. Cardiac arrest may develop and, in the absence of medical assistance, death. Malignancy is caused by the presence of serious organic disorders.

Classifications of ventricular extrasystoles

The Lown and Ryan classifications were previously often used in medical practice. They include five classes, from the lightest 0 to the heaviest 5, characterized by organic changes in the tissues of the heart. The first three classes are almost identical in their properties in both classifications:

0 - no ventricular extrasystole;

1 - extrasystoles are monotypic, appear infrequently, no more than 30 per hour;

2 - extrasystoles are monotypic, occur frequently, more than 30 per hour;

3 - polytypic extrasystoles are determined

4a - paired extrasystoles;

4b - ventricular tachycardia with the occurrence of VES of 3 or more;

5 - early ventricular extrasystoles occur.

According to Ryan, classes are described differently:

4a - monomorphic extrasystoles follow in pairs;

4b - polymorphic extrasystoles are arranged in pairs;

5 - ventricular tachycardia with the development of VVCs of 3 or more.

In modern medicine, another division of ventricular extrasystole is common, according to Myerburg from 1984. It is based on monomorphic and polymorphic ventricular extrasystoles that occur in a single variant.

In accordance with the new classification by frequency, PVCs are divided into five classes: 1 - rare extrasystoles, 2 - infrequent extraordinary contractions, 3 - moderately frequent extrasystoles, 4 - frequent premature contractions, 5 - very frequent.

According to the characteristics of the rhythm disturbance, ventricular extrasystoles are divided into types: A - monomorphic in a single number, B - polymorphic in a single number, C - running in pairs, D - unstable in their dynamics, E - stable.

Complications of ventricular extrasystole

Basically, there is a worsening of the underlying disease against which the PVC developed. The following complications and consequences also occur:

the anatomical configuration of the ventricle changes;
transition of extrasystole to fibrillation, which is dangerous with a high risk of death;
the development of heart failure is possible, which most often occurs with polytopic, multiple extrasystoles.
the most dangerous complication is sudden cardiac arrest.

Diagnosis of ventricular extrasystole

It begins with listening to the patient’s complaints, an objective examination, and listening to the activity of the heart. Next, the doctor prescribes an instrumental examination. The main diagnostic method is electrocardiography.

ECG signs of ventricular extrasystole:

the QRS complex appears prematurely;
in its shape and size, the extraordinary QRS complex differs from other normal ones;
there is no P wave in front of the QRS complex formed by the extrasystole;
after an incorrect QRS complex there is always a compensatory pause - an elongated segment of the isoline located between the extraordinary and normal contractions.

Holter ECG monitoring- often prescribed to patients with severe or unstable left ventricular failure. During the study, it is possible to determine rare extrasystoles - up to 10 per minute and frequent - more than 10 per minute.

EPI, or electrophysiological study, shown to two groups of patients. First, there are no structural changes in the heart, but correction of drug treatment is necessary. Second, organic disorders are present; diagnostics are carried out to assess the risk of sudden death.

Signal-averaged ECG- a new method that is promising in terms of identifying patients with a high probability of developing severe forms of PVCs. Also helps in determining unstable ventricular tachycardia.

Treatment of ventricular extrasystole

Before starting therapy, the following situations are assessed:

manifestations of ventricular extrasystole;
factors provoking the development of the disease, which may be associated with structural disorders, the presence of coronary heart disease, and left ventricular dysfunction.
undesirable conditions in the form of proarrhythmic effects that can complicate the course of the disease.

Depending on the course, form and severity of PVCs, treatment is carried out in the following areas:

Single, monomorphic, so-called “simple” extrasystoles, which do not cause hemodynamic disturbances, do not require specific treatment. It is enough to adjust your daily routine and diet, and treat the underlying ailment that could cause PVCs.
Unstable VES, the appearance of paired, polytopic, frequent extrasystoles lead to hemodynamic disturbances, therefore, to reduce the risk of ventricular fibrillation and cardiac arrest, antiarrhythmic drugs are prescribed. Basically, they start with beta-blockers, and if necessary, statins and aspirin are prescribed. In parallel, drugs are used to treat the underlying disease that caused the extrasystole.
Malignant PVC often requires the prescription of highly effective drugs - amiodarone, sotapol and the like, which have a good arrhythmogenic effect. If necessary, they are combined with maintenance doses of beta-blockers and ACE inhibitors.

Surgical treatment is indicated in case of ineffectiveness of drug therapy. Depending on the situation, destruction of the pathological focus of excitation, implantation of a cardioverter-defibrillator or an anti-tachycardia device may be prescribed.

Secondary prevention of ventricular extrasystole

To prevent the development of PVCs, you should first of all follow the doctor’s recommendations, which mainly consist of taking medications in a timely manner and observing a sleep and rest schedule. It is also important to eat well and eliminate bad habits. If physical inactivity is observed, you need to increase physical activity according to the body’s capabilities.

Video: Treatment of ventricular extrasystole

Normally, the heart rate is set by a special sinoatrial node, which can be found in the right atrium. It releases a charge of electricity that causes the atria to contract. It spreads throughout the myocardium through a complex system of special cells. The frequency of contractions is normally well regulated by special nerves and humorally (catecholamines, for example, adrenaline). This is how the heart adapts to the needs of its owner’s body, that is, during stress, excitement or physical activity, the contraction frequency becomes much higher.

Extrasystoles are “wedging” of additional beats into the normal rhythm of the heart; they are extraordinary and create additional difficulties for the heart. They occur when electrical charge is transferred from an area outside the sinoatrial node.

Supraventricular extrasystole occurs in two cases. Either if some area of the atrium depolarizes prematurely, or if this extraordinary impulse is sent by the atrioventricular node. In 60% of healthy people, single extrasystoles “originate” from the atrium are observed. However, they are also typical for some conditions, such as heart attack, and for mitral valve abnormalities. They can provoke uncontrolled contraction - fibrillation, and therefore extrasystoles cannot be ignored. Alcohol and caffeine will make the problem worse.

Ventricular extrasystole occurs in people of any age. This is not at all uncommon. If you record an ECG for 24 hours, then in 63% of absolutely cardiologically healthy patients single ventricular extrasystoles are detected. However, they occur in large numbers in people with abnormal heart structure. This often happens after a heart attack.

In children, ventricular extrasystole occurs approximately as often as atrial extrasystole; regular low-intensity physical exercise is usually sufficient for it to cease to occur. Only if the atrium is abnormally structured can it cause atrial fibrillation.

As for the heart, which has the correct structure, it must be said that ventricular extrasystole is not dangerous. However, if they begin to appear more often during physical activity, this is a bad symptom.

If structural anomalies are identified, you should definitely visit a cardiologist. Otherwise the situation may become life-threatening.

Risk factors for premature beats include hypertension, advanced age, ventricular hypertrophy, infarction, cardiomyopathy, calcium, magnesium, and potassium deficiency, amphetamines, tricyclic antidepressants, and digoxin, alcohol abuse, stress, caffeine, and infections.

Patients usually complain of palpitations. Ventricular extrasystole is manifested by extraordinary contractions after a normal beat and is accompanied by a feeling of “stopping” the heart. This is a strange sensation, unusual for a person, which is why it is noted as a symptom. Some people get very worried about this.

Usually the condition worsens at rest, and with exercise it goes away on its own. However, if they become stronger under load, then this is not a good symptom.

Symptoms also include fainting, weakness and a chronic cough that cannot be explained by other causes.

For those who suspect abnormalities in the structure of the heart, echocardiography and ultrasound are prescribed. The composition of the blood and the amount of thyroid hormones are checked, as well as the sufficiency of electrolytes in the blood (calcium, magnesium, potassium). Tests are often carried out in the form of forced physical activity: the frequency of extrasystoles is checked during exercise and at rest.

In most cases, extrasystoles are not a cause for alarm, but if you suspect them, go to a doctor you trust. Constant anxiety kills more people than extrasystoles.

Newspaper "News of Medicine and Pharmacy" 22 (302) 2009

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Extrasystole: clinical significance, diagnosis and treatment

Authors: V.A. Bobrov, I.V. Davydov, Department of Cardiology and Functional Diagnostics, NMAPE named after. P.L. Shupika, Kyiv

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Summary

Extrasystole is undoubtedly the most common form of cardiac arrhythmia. Extrasystole is a premature contraction directly related to the previous contraction of the main rhythm. There is another option for premature contractions - parasystole. Premature parasystolic complexes are not associated with previous contractions and do not depend on the main rhythm. The clinical significance, prognosis and treatment measures for extra- and parasystole are the same, therefore, in further discussion of the problem, we will use the term “extrasystole” to refer to any premature contractions, regardless of their mechanism.

Based on data from numerous studies using long-term ECG monitoring, it has been established that extrasystoles occur in all people - both sick and healthy. At the same time, in healthy individuals, in most cases, rare single extrasystoles are recorded, polymorphic ventricular extrasystoles (VCs) are detected less frequently, and group ventricular extrasystoles are even less common. Sometimes, in individuals without signs of any cardiovascular disease, a very large number of extrasystoles, frequent group extrasystoles, or even episodes of ventricular tachycardia (VT) are observed. In these cases, the term “idiopathic cardiac arrhythmia” (or “primary electrical heart disease”) is used.

Usually, extrasystoles are felt by the patient as a strong cardiac impulse with a dip or fading after it. Some extrasystoles may occur unnoticed by the patient. When palpating the pulse in such patients, loss of the pulse wave may be detected.

Extrasystole can be caused by any structural heart disease. It is especially often detected in patients with acute myocardial infarction and coronary heart disease. In addition, extrasystole can also occur with other myocardial damage, including subclinical ones.

The most common causes and factors associated with extrasystole:

1. Diseases of the myocardium, endocardium and coronary vessels of the heart.

2. Electrolyte imbalance, acid-base imbalance.

3. Hypoxia.

4. Traumatic influences.

5. Violation of autonomic regulation.

6. Pathological reflexes caused by diseases of the digestive organs; dystrophic changes in the cervical and thoracic spine; diseases of the bronchi and lungs, especially accompanied by a debilitating cough; BPH.

7. Diagnostic procedures.

8. Various allergic reactions.

9. Pharmacodynamic and toxic effects of medications.

Classification of extrasystoles

1) by localization - atrial, from the atrioventricular (AV) connection, ventricular;

2) according to the time of appearance in diastole - early, middle, late;

3) by frequency - rare (less than 30 per hour) and frequent (more than 30 per hour);

4) by density - single and paired;

5) according to periodicity - sporadic and allorhythmic (bigeminy, trigeminy, etc.);

6) according to the conduction of extrasystoles - polymorphic.

In Ukraine, when interpreting data from Holter ECG monitoring (HM ECG) in patients with ventricular arrhythmias, the classification of B. Lown and M. Wolf (1971) is traditionally used:

- Rare single monomorphic extrasystoles - less than 30 per hour.

- Frequent extrasystoles - more than 30 per hour.

- Polymorphic extrasystoles.

- Repeated forms of extrasystoles: 4A - paired, 4B - group (including episodes of ventricular tachycardia).

— Early ventricular extrasystoles (type “R on T”).

It was assumed that high gradations of extrasystoles (classes 3-5) are the most dangerous. However, further studies found that the clinical and prognostic significance of extrasystole (and parasystole) is almost entirely determined by the nature of the underlying disease, the degree of organic damage to the heart and the functional state of the myocardium. In persons without signs of organic heart damage, the presence of extrasystole (regardless of frequency and nature) does not affect the prognosis and does not pose a threat to life. In patients with severe organic myocardial damage, especially in the presence of post-infarction cardiosclerosis or signs of heart failure (HF), detection of frequent group ventricular extrasystole may be an additional prognostically unfavorable sign. But even in these cases, extrasystoles do not have an independent prognostic value, but are a reflection of myocardial damage and left ventricular dysfunction. This classification was created to systematize ventricular cardiac arrhythmias in patients with acute myocardial infarction (MI), but it does not meet the needs of risk stratification and the choice of differentiated treatment tactics in post-infarction patients. The variants of ventricular cardiac arrhythmias are shown in more detail in the classification of R. Myerburg (1984), which is convenient to use when interpreting the results of a HM ECG.

When conducting daily ECG monitoring, the statistical norm for extrasystoles is considered to be approximately up to 200 supraventricular extrasystoles and up to 200 ventricular extrasystoles per day. Extrasystoles can be single or paired. Three or more extrasystoles in a row are usually called tachycardia (“jogs” of tachycardia, “short episodes of unstable tachycardia”). Unsustained tachycardia refers to episodes of tachycardia lasting less than 30 seconds. Sometimes the definition of “group” or “salvo” extrasystoles is used to designate 3-5 extrasystoles in a row. Very frequent extrasystoles, especially paired and recurrent “jogs” of unstable tachycardia, can reach the level of continuously recurrent tachycardia, in which 50 to 90% of contractions during the day are ectopic complexes, and sinus contractions are recorded in the form of single complexes or short short-term episodes of sinus rhythm .

From a practical point of view, the “prognostic” classification of ventricular arrhythmias proposed in 1983 by J. Bigger is very interesting:

— Safe arrhythmias- any extrasystoles and episodes of unstable ventricular tachycardia that do not cause hemodynamic disturbances in persons without signs of organic heart damage.

— Potentially dangerous arrhythmias- ventricular arrhythmias that do not cause hemodynamic disturbances in persons with organic heart disease.

— Life-threatening arrhythmias(“malignant” arrhythmias) - episodes of sustained ventricular tachycardia, ventricular arrhythmias accompanied by hemodynamic disturbances, or ventricular fibrillation (VF). Patients with life-threatening ventricular arrhythmias usually have significant organic heart disease (or “electrical heart disease,” eg, long QT syndrome, Brugada syndrome).

However, as noted, ventricular extrasystole does not have an independent prognostic value. Extrasystoles themselves are in most cases safe. Extrasystole is even called a “cosmetic” arrhythmia, thereby emphasizing its safety. Even “jogs” of unstable ventricular tachycardia are also classified as “cosmetic” arrhythmias and are called “enthusiastic escape rhythms”.

Detection of extrasystole (as well as any other variant of rhythm disturbances) is the reason for an examination aimed primarily at identifying the possible cause of arrhythmia, heart disease or extracardiac pathology and determining the functional state of the myocardium.

Is it always necessary to treat extrasystolic arrhythmia?

Asymptomatic or low-symptomatic extrasystoles, if after examination of the patient no heart disease is detected, do not require special treatment. It is necessary to explain to the patient that the so-called benign low-symptomatic extrasystole is safe, and taking antiarrhythmic drugs can be accompanied by unpleasant side effects or even cause dangerous complications. First of all, it is necessary to eliminate all potentially arrhythmogenic factors: alcohol, smoking, strong tea, coffee, taking sympathomimetic drugs, psycho-emotional stress. You should immediately begin to follow all the rules of a healthy lifestyle. Such patients are advised to undergo clinical observation with echocardiography approximately 2 times a year to identify possible structural changes and deterioration in the functional state of the left ventricle. Thus, in one study, during long-term observation of 540 patients with idiopathic frequent extrasystoles (more than 350 extrasystoles per hour and more than 5000 per day), an enlargement of the heart cavities (arrhythmogenic cardiomyopathy) was revealed in 20% of patients. Moreover, enlargement of the heart cavities was more often observed in the presence of atrial extrasystole.

If the examination reveals that the extrasystoles are associated with some other disease (diseases of the gastrointestinal tract, endocrine diseases, inflammatory diseases of the heart muscle), the underlying disease is treated.

Extrasystole caused by disorders of the nervous system, psycho-emotional overload, is treated by prescribing sedatives (strawberry, lemon balm, motherwort, peony tincture) or sedatives (Relanium, rudotel). If extrasystoles occur during treatment with cardiac glycosides, cardiac glycosides are discontinued. If during a HM ECG the number of extrasystoles exceeds 200 and the patient has complaints or has heart disease, treatment is prescribed.

Indications for the treatment of extrasystole:

1) very frequent, usually group, extrasystoles, causing hemodynamic disturbances;

2) pronounced subjective intolerance to the sensation of interruptions in the heart’s function;

3) detection during repeated echocardiographic examination of worsening indicators of the functional state of the myocardium and structural changes (decrease in ejection fraction, dilatation of the left ventricle).

General principles for the treatment of arrhythmias:

— In most cases, arrhythmia is a consequence of an underlying disease (secondary), so treatment of the underlying disease can help treat the rhythm disorder. For example, thyrotoxicosis with atrial fibrillation or coronary heart disease with ventricular extrasystole.

— Most arrhythmias are accompanied by psychosomatic disorders that require psychocorrection. If non-drug measures are insufficient, alprazolam and modern antidepressants are most effective.

— Metabolic therapy can achieve some success in the treatment of arrhythmias. However, first-generation drugs (riboxin, inosium, potassium orotate) are extremely ineffective. Modern drugs are more preferable (Neoton, Espalipon, Trimetazidine, Magnerot, Solcoseryl, Actovegin).

Drug treatment of extrasystole

Indications for prescribing antiarrhythmic drugs (AAP) for extrasystolic arrhythmia are the following clinical situations:

1) progressive course of heart disease with a significant increase in the number of extrasystoles;

2) frequent, polytopic, paired, group and early (“R on T”) ventricular extrasystoles, threatened in the future by the occurrence of paroxysmal ventricular tachycardia or ventricular fibrillation; 3) allorhythmia (bi-, tri-, quadrigeminy), short “jogs” of atrial tachycardia, which are accompanied by signs of heart failure; 4) extrasystolic arrhythmia against the background of diseases that are accompanied by an increased risk of life-threatening arrhythmias (mitral valve prolapse, long Q-T interval syndrome, etc.); 5) the occurrence or increase in the frequency of extrasystoles during attacks of angina or acute MI; 6) preservation of PVCs after the end of the attack of VT and VF; 7) extrasystoles against the background of abnormal conduction pathways (WPW and CLC syndromes).

Typically, treatment begins when the number of extrasystoles exceeds 700 per day. The prescription of medications takes place with mandatory consideration of the types of extrasystoles and heart rate. The selection of antiarrhythmic drugs is made individually and only by a doctor. After prescribing the drug, treatment is monitored using Holter monitoring. The best results are achieved when Holter monitoring is performed once a month, but in practice this is difficult to achieve. If the effect of the drug is good, extrasystoles disappear or are significantly reduced and this effect persists for up to two months, discontinuation of the drug is possible. But at the same time, the dose of the medication is gradually reduced over a long period of time, since abrupt discontinuation of treatment leads to the recurrence of extrasystoles.

Treatment of extrasystole in certain clinical situations

Treatment of extrasystole is carried out by trial and error, sequentially (for 3-4 days) assessing the effect of taking antiarrhythmic drugs in average daily doses (taking into account contraindications), choosing the most suitable one for a given patient. It may take several weeks or even months to evaluate the antiarrhythmic effect of amiodarone (the use of higher doses of amiodarone, for example 1200 mg/day, can reduce this period to several days).

Antiarrhythmic drugs (AAP) do not cure arrhythmia, but only eliminate it while taking the drugs. At the same time, adverse reactions and complications associated with taking almost all drugs can be much more unpleasant and dangerous than extrasystole. Thus, the mere presence of extrasystole (regardless of frequency and gradation) is not an indication for prescribing AAP.

In any case, treatment of extrasystole with antiarrhythmic drugs does not improve the prognosis. Several large controlled clinical trials have revealed a marked increase in overall mortality and the incidence of sudden death (2-3 times or more) in patients with organic heart disease while taking class I AAP, despite the effective elimination of extrasystoles and episodes of ventricular tachycardia. The most famous study that first identified the discrepancy between the clinical effectiveness of drugs and their impact on prognosis is the CAST study. The CAST (Cardiac Arrhythmia Suppression Study) study in patients who had suffered a myocardial infarction, against the background of effective elimination of ventricular extrasystoles with class IC drugs (flecainide, encainide and moracizine), revealed a significant increase in overall mortality by 2.5 times and the incidence of sudden death by 3.6 times compared to patients taking placebo. The results of the study forced us to reconsider the treatment tactics not only for patients with arrhythmias, but also for cardiac patients in general. The CAST study is one of the main studies in the development of evidence-based medicine. Only when taking β-blockers and amiodarone was there a decrease in mortality in patients with post-infarction cardiosclerosis, heart failure, or resuscitated patients. However, the positive effect of amiodarone and especially β-blockers did not depend on the antiarrhythmic effect of these drugs.

Most often, supraventricular extrasystole does not require specialized treatment. The main indications for antiarrhythmic therapy are hemodynamic significance and subjective intolerance. In the second case, you should remember about tranquilizers and antidepressants. Arrhythmia will not disappear while taking them, but the patient’s attitude towards it will change significantly.

For the treatment of symptomatic, including group, supraventricular extrasystole in patients with structural heart disease without signs of HF, treatment begins with calcium antagonists (verapamil, diltiazem) or β-blockers (propranolol, metoprolol, bisoprolol, betaxolol). If there is no effect from these drugs, class I drugs or a combination of AAPs with different mechanisms of action are prescribed. The most tested combinations of AAP are: disopyramide + β-blocker; propafenone + β-blocker; class IA or IB drug + verapamil. Amiodarone is considered as a reserve drug in situations where its prescription is justified taking into account group extrasystole and the severe clinical symptoms associated with it. In the acute period of MI, special treatment for supraventricular extrasystole is usually not indicated.

Potentially “malignant” ventricular arrhythmias occur against the background of structural heart disease, such as coronary artery disease, or after a MI. Taking this into account, patients first of all require adequate treatment of the underlying disease. For this purpose, standard risk factors are corrected (hypertension, smoking, hypercholesterolemia, diabetes mellitus), drugs are prescribed whose effectiveness has been proven in patients with coronary artery disease (aspirin, β-blockers, statins) and in heart failure (ACE inhibitors, β-blockers, aldosterone antagonists). ).

The selection of drug therapy is carried out individually. If the patient has coronary artery disease, it is better not to use class I drugs (except propafenone). If there are indications for prescribing AAP in patients with organic heart disease, β-blockers, amiodarone and sotalol are used. The effectiveness of amiodarone in suppressing ventricular extrasystoles is 90-95%, sotalol - 75%, class IC drugs - from 75 to 80%.

In patients without signs of organic heart damage, in addition to these drugs, class I AAPs are used: etacizin, allapinin, propafenone, kinidin durules. Etatsizin is prescribed 50 mg 3 times a day, allapinin - 25 mg 3 times a day, propafenone - 150 mg 3 times a day, quinidin durules - 200 mg 2-3 times a day.

Some controversy exists regarding the use of amiodarone. On the one hand, some cardiologists prescribe amiodarone as a last resort - only if there is no effect from other drugs (believing that amiodarone quite often causes side effects and requires a long “saturation period”). On the other hand, it may be more rational to start selecting therapy with amiodarone as the most effective and convenient drug to take. Amiodarone in small maintenance doses (100-200 mg per day) rarely causes serious side effects or complications and is likely to be safer and better tolerated than most other antiarrhythmic drugs. In any case, if there is organic heart damage, the choice is small: β-blockers, amiodarone or sotalol. If there is no effect from taking amiodarone (after a “saturation period” - at least 600-1000 mg / day for 10 days), you can continue taking it at a maintenance dose - 0.2 g / day and, if necessary, evaluate the effect of sequential addition class IC drugs (etacizin, propafenone, allapinin) in half doses.

In patients with extrasystole against the background of bradycardia, the selection of treatment begins with the prescription of drugs that accelerate heart rate: you can try taking pindolol (Wisken), aminophylline (Teopec) or class I drugs (etacizin, allapinin, kinidin durules). Prescribing anticholinergic drugs such as belladonna or sympathomimetics is less effective and is accompanied by numerous side effects.

In case of ineffectiveness of monotherapy, the effect of combinations of various AAPs in reduced doses is assessed. Particularly popular are combinations of AAPs with β-blockers or amiodarone. There is evidence that the simultaneous administration of β-blockers (and amiodarone) neutralizes the increased risk from taking any antiarrhythmic drugs. In the CAST study, there was no increase in mortality in post-myocardial infarction patients who took β-blockers along with class IC drugs. Moreover, a 33% reduction in the incidence of arrhythmic death was found! With this combination, there was an even greater reduction in mortality than with either drug alone.

If the heart rate exceeds 70-80 beats/min at rest and the P-Q interval is within 0.2 s, then there is no problem with the simultaneous administration of amiodarone and β-blockers. In the case of bradycardia or AV block of I-II degree, the administration of amiodarone, β-blockers and their combination requires the implantation of a pacemaker operating in DDD (DDDR) mode. There are reports of increased effectiveness of antiarrhythmic therapy when combining AAP with ACE inhibitors, angiotensin receptor blockers, statins and omega-3 unsaturated fatty acids.

In patients with heart failure, a noticeable decrease in the number of extrasystoles can be observed while taking ACE inhibitors and aldosterone antagonists.

It should be noted that daily ECG monitoring to assess the effectiveness of antiarrhythmic therapy has lost its importance, since the degree of suppression of extrasystoles does not affect the prognosis. In the CAST study, a pronounced increase in mortality was noted against the background of achieving all criteria for a complete antiarrhythmic effect: a reduction in the total number of extrasystoles by more than 50%, paired extrasystoles by at least 90%, and complete elimination of episodes of ventricular tachycardia. The main criterion for the effectiveness of treatment is improvement in well-being. This usually coincides with a decrease in the number of extrasystoles, and determining the degree of suppression of extrasystoles is not important.

In general, the sequence of selection of AAP in patients with organic heart disease in the treatment of recurrent arrhythmias, including extrasystole, can be presented as follows:

- β-blocker, amiodarone or sotalol;

- amiodarone + β-blocker.

Combinations of drugs:

- β-blocker + class I drug;

— amiodarone + class IC drug;

— sotalol + class IC drug;

— amiodarone + β-blocker + class IC drug.

In patients without signs of organic heart disease, you can use any drugs in any sequence or use the regimen proposed for patients with organic heart disease.

List of literature / References

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3. Denisyuk V.I. Dzyak G.I. Moroz V.M. Treatment of arrhythmias: ways to increase the effectiveness and safety of antiarrhythmic drugs. - Vinnitsa: State Enterprise GKF, 2005. - 640 p.

4. Diagnosis and diagnosis of ex-trasystole and parasystole: Method. rec. / Bobrov V.O. Furkalo M.K. Kuts V.O. that in. - K. Ukrmedpatentinform, 1999. - 20 p.

5. Doshitsyn V.L. Treatment of patients with ventricular arrhythmias // Rus. honey. magazine - 2001. - T. 9, No. 18(137). - pp. 736-739.

6. Zharinov O.Y. Kuts V.O. Diagnosis and management of patients with extrasystole // Ukrainian Cardiological Journal. - 2007. - 4. - P. 96-110.

7. Ventricular rhythm disturbances in acute myocardial infarction: Method. rec. / Dyadyk A.I. Bagriy A.E. Smirnova L.G. and others - K. Chetverta Khvilya, 2001. - 40 p.

8. Clinical classification of damage to the rhythm and vigor of the heart // Ukr. cardiol. magazine - 2000. - No. 1-2. — P. 129-132.

9. Kushakovsky M.S. Zhuravleva N.B. Arrhythmias and heart block. Atlas of ECG. - L. Medicine, 1981. - 340 p.

10. Parkhomenko A.N. Management of patients after sudden circulatory arrest: are there new methodological approaches today? //Ukr. honey. clock-writer - 2001. - No. 1. - P. 50-53.

11. Stratification of risk factors and prevention of rapt cardiac death: Recommended method. // Bobrov V.O. Zharinov O.Y. Sichov O.S. that in. - K. Ukrmedpatentinform, 2002. - 39 p.

12. Sychev O.S. Bezyuk N.N. Basic principles of management of patients with ventricular arrhythmias // Health of Ukraine. - 2009. - 10. - pp. 33-35.

13. Fomina I.G. Heart rhythm disturbances. - M. Publishing house "Russian Doctor", 2003. - 192 p.

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17. Fralkis J.P. Pothier C.E. Blackstone E.N. Lauer M.S. Frequent ventricular ectopy after exercise as a predictor of death // The New England J. of Medicine. - 2003. - 348. - 9. - 781-790.

18. Iseri L.T. Role of Magnesium in cardiac tachyarrhythmias // Am. J. Cardiol. - 1990. - 65. - 47K.

19. Lazzara R. Antiarrhythmic drugs and torsade de pointers // Eur. Heart J. - 1993. - 14, Suppl H. - 88-92.

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21. Pauly D.F. Pepine C.J. Ischemic Heart Disease: Metabolic Approaches to Management // Clin. Cardiol. - 2004. - 27. - 439-441.

22. Windhagen-Mahnert B. Kadish A.H. Application of noninvasive and invasive tests for risk assessment in patients with ventricular arrhythmias // Cardiol. Clin. - 2000. - 18(2). - 243-63.

Ventricular extrasystole

Ventricular extrasystole is a premature excitation of the heart that occurs under the influence of impulses emanating from various parts of the conduction system of the ventricles. The source of ventricular extrasystole in most cases is the branches of the His bundle and Purkinje fibers.

Ventricular extrasystole is the most common heart rhythm disorder. Its frequency depends on the diagnostic method and the population of subjects. When recording an ECG in 12 leads at rest, ventricular extrasystoles are detected in approximately 5% of healthy young people, while with Holter ECG monitoring for 24 hours their frequency is 50%. Although most of them are represented by single extrasystoles, complex forms can also be detected. The prevalence of ventricular extrasystoles increases significantly in the presence of organic heart diseases, especially those accompanied by damage to the ventricular myocardium, correlating with the severity of its dysfunction. Regardless of the presence or absence of pathology of the cardiovascular system, the frequency of this rhythm disorder increases with age. A connection between the occurrence of ventricular extrasystoles and the time of day was also noted. So, in the morning they are observed more often, and at night, during sleep, less often. The results of repeated Holter ECG monitoring showed significant variability in the number of ventricular extrasystoles in 1 hour and 1 day, which significantly complicates the assessment of their prognostic value and treatment effectiveness.

Causes of ventricular extrasystoles. Ventricular extrasystole occurs both in the absence of organic heart diseases and in their presence. In the first case, it is often (but not necessarily!) associated with stress, smoking, drinking coffee and alcoholic beverages, which cause an increase in the activity of the sympathetic-adrenal system. However, in a significant proportion of healthy individuals, extrasystoles occur for no apparent reason.

Although ventricular extrasystole can develop with any organic heart disease, its most common cause is ischemic heart disease. With Holter ECG monitoring within 24 hours, it is detected in 90% of such patients. Patients with both acute coronary syndromes and chronic ischemic heart disease, especially those who have suffered a myocardial infarction, are susceptible to the occurrence of ventricular extrasystoles. Acute cardiovascular diseases, which are the most common causes of ventricular extrasystole, also include myocarditis and pericarditis, and chronic diseases include various forms of cardiomyopathies and hypertensive heart, in which its occurrence is facilitated by the development of ventricular myocardial hypertrophy and congestive heart failure. Despite the absence of the latter, ventricular extrasystoles are often found with mitral valve prolapse. Their possible causes also include iatrogenic factors such as overdose of cardiac glycosides, the use of ß-adrenergic stimulants and, in some cases, membrane-stabilizing antiarrhythmic drugs, especially in the presence of organic heart diseases.

Symptoms There are no complaints or consist of a feeling of “freezing” or “push” associated with increased post-extrasystolic contraction. Moreover, the presence of subjective sensations and their severity do not depend on the frequency and cause of extrasystoles. With frequent extrasystoles, patients with severe heart disease rarely experience weakness, dizziness, anginal pain and shortness of breath.

Main electrocardiographic signs of ventricular extrasystole are:

premature extraordinary appearance on the ECG of an altered ventricular QRS complex;

significant expansion and deformation of the extrasystolic QRS complex;

the location of the RS-T segment and the T wave of the extrasystole is discordant to the direction of the main wave of the QRS’ complex;

absence of a P wave before the ventricular extrasystole;

the presence in most cases of a complete compensatory pause after a ventricular extrasystole.

Course and prognosis of ventricular extrasystole depend on its form, the presence or absence of organic heart disease and the severity of ventricular myocardial dysfunction. It has been proven that in persons without structural pathology of the cardiovascular system, ventricular extrasystoles, even frequent and complex ones, do not have a significant effect on the prognosis. At the same time, in the presence of organic heart damage, ventricular extrasystoles can significantly increase the risk of sudden cardiac death and overall mortality, initiating persistent ventricular tachycardia and ventricular fibrillation.

Treatment and secondary prevention with ventricular extrasystole, there are 2 goals - to eliminate the symptoms associated with it and improve the prognosis. This takes into account the class of extrasystole, the presence of organic heart disease and its nature and severity of myocardial dysfunction, which determine the degree of risk of potentially fatal ventricular arrhythmias and sudden death.

In persons without clinical signs of organic cardiac pathology, asymptomatic ventricular extrasystole, even of high gradations according to V. Lown, does not require special treatment. Patients need to be explained that the arrhythmia is benign, recommend a diet enriched with potassium salts, and the exclusion of such provoking factors as smoking, drinking strong coffee and alcohol, and in case of physical inactivity, increase physical activity. Treatment begins with these non-drug measures in symptomatic cases, moving to drug therapy only if they are ineffective.

First-line drugs in the treatment of such patients are sedatives (herbal medicines or small doses of tranquilizers, for example diazepam 2.5-5 mg 3 times a day) and beta-blockers. In most patients, they provide a good symptomatic effect, not only due to a decrease in the number of extrasystoles, but also, independently of it, as a result of a sedative effect and a decrease in the strength of post-extrasystolic contractions. Treatment with beta-blockers begins with small doses, for example, 10-20 mg of propranolol (obzidan, anaprilin) 3 times a day, which, if necessary, are increased under heart rate control. In some patients, however, a slowdown in sinus rhythm is accompanied by an increase in the number of extrasystoles. With initial bradycardia associated with increased tone of the parasympathetic part of the autonomic nervous system, characteristic of young people, the reduction of extrasystole can be facilitated by an increase in the automaticity of the sinus node with the help of such drugs that have an anticholinergic effect, such as belladonna preparations (bellataminal tablets, bellaid, etc.) and itropium .

In relatively rare cases of ineffectiveness of sedative therapy and correction of the tone of the autonomic nervous system, with a pronounced disturbance in the well-being of patients, it is necessary to resort to tableted antiarrhythmic drugs IA (retarded form of quinidine, procainamide, disopyramide), IB (mexiletine) or 1C (flecainide, propafenone) classes. Due to the significantly higher frequency of side effects compared to beta-blockers and the favorable prognosis in such patients, the use of membrane-stabilizing agents should be avoided if possible.

ß-Adrenergic blockers and sedatives are also the drugs of choice in the treatment of symptomatic ventricular extrasystole in patients with mitral valve prolapse. As in cases of absence of organic heart disease, the use of class I antiarrhythmic drugs is justified only in cases of severe impairment of well-being.

In the group of arrhythmias of the extrasystolic type, ventricular extrasystole occupies one of the most important places in terms of significance for prognosis and treatment. An extraordinary contraction of the heart muscle occurs following a signal from an ectopic (additional) source of excitation.

According to the International Classification of Diseases (ICD-10), this pathology is coded I 49.4.
The prevalence of extrasystoles among sick and healthy people was established using long-term Holter heart rate monitoring. Extrasystoles from the ventricles are detected in 40–75% of cases of examined adults.

Where is the source of extrasystoles located?

Ventricular extrasystoles occur in the wall of the left or right ventricle, most often directly in the fibers of the conduction system. If extrasystole occurs at the end of the ventricular relaxation phase, then it coincides in time with the next contraction of the atria. The atrium does not empty completely; a reverse wave travels through the vena cava.

Typically, ventricular extrasystoles cause contraction only of the ventricles themselves and do not transmit impulses in the opposite direction to the atria. “Supraventricular” refers to extrasystoles from ectopic foci located above the level of the ventricles, in the atria, and atrioventricular node. They can be combined with ventricular ones. There are no pancreatic extrasystoles.

The correct rhythm from the sinus node is maintained and disrupted only by compensatory pauses after extraordinary beats.

The order of occurrence of impulses must not be disturbed

Causes

The reasons for ventricular extrasystole appear in heart disease:

inflammatory nature (myocarditis, endocarditis, intoxication);
myocardial ischemia (foci of cardiosclerosis, acute infarction);
metabolic-dystrophic changes in the muscle and conduction system (impaired potassium-sodium electrolyte ratio in myocytes and intercellular space);
a sharp depletion of the energy supply of cells caused by malnutrition, lack of oxygen in acute and chronic heart failure, and decompensated defects.

Ventricular extrasystoles may appear in people with a healthy cardiovascular system due to:

irritation of the vagus nerve (due to overeating, insomnia, mental work);
increased tone of the sympathetic nerve (smoking, physical work, stress, hard work).

If there are two sources of impulse formation in the heart, then the main one is the one that is capable of a higher frequency. Therefore, most often it remains normal. But extrasystoles can also occur against the background of atrial fibrillation.

Types of ventricular extrasystoles

The classification of ventricular extrasystole takes into account the frequency of pathological impulses and the localization of ectopic foci.

Extrasystoles from the ventricles, as well as from other foci, can be single (one per 15-20 normal contractions) or group (3-5 ectopic contractions between normal ones).

Single extrasystole against the background of sinus rhythm

The constant repetition of extraordinary single contractions after each normal one is called bigeminy, after two - trigeminy. according to the type of bigeminy or trigeminy, it refers to allorhythmias (irregular but persistent rhythm disturbance).

Depending on the number of identified foci, extrasystoles are distinguished:

monotopic (from one focus);
polytopic (more than one).

According to their location in the ventricles, the most common are left ventricular extraordinary contractions. Right ventricular extrasystole is less common, possibly due to the anatomical features of the vascular bed and rare ischemic lesions of the right heart.

Classification B.Lown - M.Wolf

Not all specialists use the existing classification of ventricular extrasystole according to Laun and Wolf. She offers five degrees of extrasystole during myocardial infarction according to the risk of developing fibrillation:

degree 1 - monomorphic extraordinary contractions are recorded (no more than 30 per hour of observation);
degree 2 - more frequent, from one focus (over 30 per hour);
degree 3 - polytopic extrasystole;
degree 4 - subdivided depending on the ECG pattern of the rhythm (“a” - paired and “b” - volley);
degree 5 - the most dangerous type “R on T” in a prognostic sense is registered, which means that the extrasystole “climbed” onto the previous normal contraction and is capable of disrupting the rhythm.

In addition, a “zero” degree was allocated for patients without extrasystole.

Group extrasystoles

M. Ryan's proposals for gradation (classes) supplemented the B. Lown - M. Wolf classification for patients without myocardial infarction.

In them, “gradation 1”, “gradation 2” and “gradation 3” completely coincide with Launov’s interpretation.

The rest have been changed:

“gradation 4” - considered in the form of paired extrasystoles in monomorphic and polymorphic versions;
included in “gradation 5”.

Varieties of allorhythmia

How does extrasystole feel to patients?

The symptoms of ventricular extrasystole do not differ from any extraordinary contractions of the heart. Patients complain of a feeling of “fading” of the heart, stopping, and then a strong push in the form of a blow. Some people feel:

weakness,
dizziness,
headache.

Rarely, extrasystole is accompanied by a coughing movement.

A more colorful description is the “turning over” of the heart, “thrusting in the chest.”

Diagnostics

The use of electrocardiography (ECG) in diagnostics is of great importance, since the technique is not difficult to master; the equipment is used for recording at home, in an ambulance.

Taking an ECG takes 3-4 minutes (including the application of electrodes). On the current recording during this time, it is not always possible to “catch” extrasystoles and characterize them.

The solution is the Holter technique of long-term ECG recording with subsequent interpretation of the results. The method allows you to register even single extraordinary contractions.

To examine healthy individuals, exercise tests are used; an ECG is done twice: first at rest, then after twenty squats. For some professions that involve heavy workloads, it is important to identify possible violations.

Ultrasound of the heart and blood vessels can exclude various cardiac causes.

It is important for the doctor to establish the cause of the arrhythmia, so the following are prescribed:

general blood analysis;
C-reactive protein;
globulin level;
blood for thyroid-stimulating hormones;
electrolytes (potassium);
cardiac enzymes (creatine phosphokinase, lactate dehydrogenase).

Extrasystole remains idiopathic (of unclear origin) if the patient does not have any diseases or provoking factors during examination.

Features of extrasystole in children

Arrhythmia is detected in newborn babies at the first listening. Extrasystoles from the ventricles may have congenital roots (various developmental defects).

Acquired ventricular extrasystole in childhood and adolescence is associated with previous rheumatic carditis (after tonsillitis), infections complicated by myocarditis.

A special group of causes is hereditary myocardial pathology, called arrhythmogenic ventricular dysplasia. The disease often leads to sudden death.

Extrasystole in older children accompanies disorders in the endocrine system and occurs when:

overdose of drugs;
in the form of a reflex from a distended gallbladder with dyskinesia;
influenza intoxication, scarlet fever, measles;
food poisoning;
nervous and physical overload.

In 70% of cases, ventricular extrasystole is detected in a child by chance during a routine examination.

Grown-up children notice interruptions in heart rhythm and extraordinary shocks, complaining of stabbing pain to the left of the sternum. In adolescents, a combination with vegetative-vascular dystonia is observed.

Depending on the predominance of vagal or sympathetic nervous regulation, extrasystoles are observed:

in the first case - against the background of bradycardia, during sleep;
in the second - during games, along with tachycardia.

Diagnosis in childhood goes through the same stages as in adults. In treatment, more attention is paid to daily routine, balanced nutrition, and mild sedatives.

Clinical examinations of children allow us to identify early changes

Extrasystole in pregnant women

Pregnancy in a healthy woman can cause rare ventricular extrasystoles. This is more typical for the second trimester and is associated with an imbalance of electrolytes in the blood and a high position of the diaphragm.

The presence of diseases of the stomach, esophagus, and gallbladder in a woman causes reflex extrasystole.

If a pregnant woman complains about a feeling of irregular rhythm, it is necessary to conduct an examination. After all, the pregnancy process significantly increases the load on the heart and contributes to the manifestation of hidden symptoms of myocarditis.

An obstetrician-gynecologist prescribes a special diet, potassium and magnesium supplements. In most cases, no treatment is required. Persistent group extrasystole requires clarification of the cause and consultation with a cardiologist.

Treatment

Treatment of ventricular extrasystole includes all the requirements of a healthy diet and diet.

stop smoking, drinking alcohol, strong coffee;
Be sure to consume potassium-containing foods in your diet (jacket potatoes, raisins, dried apricots, apples);
you should refrain from lifting weights and strength training;
If sleep suffers, you should take mild sedatives.

Drug therapy includes:

if the arrhythmia is poorly tolerated by the patient;
increased frequency of idiopathic (unclear) group extrasystole;
high risk of developing fibrillation.

The doctor's arsenal includes antiarrhythmic drugs of varying strengths and directions. The purpose must be consistent with the main reason.

The drugs are used very carefully in case of a previous heart attack, the presence of ischemia and symptoms of heart failure, and various blockades of the conduction system.

During treatment, the effectiveness is judged by repeated Holter monitoring: a reduction in the number of extrasystoles by 70–90% is considered a positive result.

Surgical treatment options

The lack of effect of conservative therapy and the presence of a risk of fibrillation is an indication for radiofrequency ablation (RFA). The procedure is performed in a cardiac surgery hospital under sterile conditions in the operating room. Under local anesthesia, a catheter with a source of radiofrequency radiation is inserted into the patient's subclavian vein. The ectopic focus is cauterized by radio waves.

With a good hit on the cause of the impulses, the procedure ensures effectiveness in the range of 70 – 90%.

A probe is inserted into the heart through a catheter

Use of folk remedies

Folk remedies are used for extrasystole of a functional nature. If there are organic changes in the heart, you should consult your doctor. Some methods may be contraindicated.

Several popular recipes
At home, it is convenient and easy to brew medicinal herbs and plants in a thermos.

In this way, decoctions are prepared from the roots of valerian, calendula, and cornflower. Brew should be at the rate of 1 tablespoon of dry plant material per 2 glasses of water. Keep in a thermos for at least three hours. Can be brewed overnight. After straining, drink ¼ glass 15 minutes before meals.
Horsetail is brewed in the proportion of a tablespoon to 3 glasses of water. Drink a spoon up to six times a day. Helps with heart failure.
Alcohol tincture of hawthorn can be bought at a pharmacy. Drink 10 drops three times a day. To prepare it yourself, you need 10 g of dry fruits for every 100 ml of vodka. Leave for at least 10 days.
Honey recipe: mix squeezed radish juice and honey in equal volumes. Take a tablespoon three times a day.

All decoctions are stored in the refrigerator.

Modern forecasting

Over the 40 years of existence, the above classifications have helped train doctors and enter the necessary information into automatic ECG interpretation programs. This is important for quickly obtaining research results in the absence of a specialist nearby, in the case of a remote (in rural area) examination of the patient.

To predict dangerous situations, it is important for a doctor to know:

if a person has ventricular extrasystoles, but there is no confirmed heart disease, their frequency and location do not matter for the prognosis;
the risk to life is increased for patients with heart defects, organic changes in hypertension, myocardial ischemia only in the case of a reduction in the strength of the heart muscle (increasing heart failure);
The risk for patients after myocardial infarction should be considered high if there are more than 10 ventricular extrasystoles per hour of observation and a reduced volume of blood ejection is detected (extensive infarction, heart failure).

The patient should consult a doctor and be examined for any unclear interruptions in heart rhythm.