Supraventricular premature beats
- Antonis S Manolis, MD
Antonis S Manolis, MD
- Professor of Cardiology
- Athens University School of Medicine
Supraventricular premature beats represent premature activation of the atria from a site other than the sinus node and can originate from the atria or the atrioventricular node (called junctional premature beats), though the vast majority are atrial in origin. Atrial premature beats (APBs), also referred to as atrial premature complexes, premature atrial beats, premature atrial complexes, or atrial extrasystoles, are triggered from the atrial myocardium in a variety of situations and occur in a broad spectrum of the population. This includes patients without structural heart disease and those with any form of cardiac disease, independent of severity.
The prevalence, mechanisms, clinical manifestations, diagnosis, and treatment of APBs will be presented here. A discussion of ventricular premature beats is presented separately. (See "Ventricular premature beats".)
APBs are fairly ubiquitous, occurring commonly in both young and elderly subjects and in those with and without significant heart disease.
The prevalence of APBs is highly dependent upon the technique used for evaluation. APBs are less commonly seen on standard 10-second electrocardiogram compared with 24-hour or longer duration Holter monitoring. In a cross-sectional analysis of 1742 Swiss adults (50 years of age or older) from the general population who underwent Holter monitoring for 24 hours, 99 percent had at least one APB during the monitoring period . In this Swiss cohort, the frequency of APBs steadily increased with age, with rates of 0.8, 1.4, and 2.6 APBs per hour among participants aged 50 to 55 years, 60 to 65 years, and 70 or more years, respectively . Similar findings of greater APB frequency with advancing age have been reported in other cohorts as well [2-4].
The presence and frequency of APBs is dependent upon the presence of structural heart disease. APBs are particularly frequent in patients with mitral valve disease and in those with left ventricular dysfunction regardless of etiology. However, the high prevalence of APBs in the normal population makes such associations uncertain. (See 'Etiology' below.)
- Conen D, Adam M, Roche F, et al. Premature atrial contractions in the general population: frequency and risk factors. Circulation 2012; 126:2302.
- Southall DP, Richards J, Mitchell P, et al. Study of cardiac rhythm in healthy newborn infants. Br Heart J 1980; 43:14.
- Folarin VA, Fitzsimmons PJ, Kruyer WB. Holter monitor findings in asymptomatic male military aviators without structural heart disease. Aviat Space Environ Med 2001; 72:836.
- Rossi A. Twenty-four-hour electrocardiographic study in the active very elderly. Cardiology 1987; 74:159.
- Toivonen L. Spontaneous variability in the frequency of ventricular premature complexes over prolonged intervals and implications for antiarrhythmic treatment. Am J Cardiol 1987; 60:608.
- Pratt CM, Delclos G, Wierman AM, et al. The changing base line of complex ventricular arrhythmias. A new consideration in assessing long-term antiarrhythmic drug therapy. N Engl J Med 1985; 313:1444.
- WALLACE AG, DAGGETT WM. RE-EXCITATION OF THE ATRIUM. "THE ECHO PHENOMENON". Am Heart J 1964; 68:661.
- DE CARVALHO AP, DE MELLO WC, HOFFMAN BF. Electrophysiological evidence for specialized fiber types in rabbit atrium. Am J Physiol 1959; 196:483.
- Wit AL, Cranefield PF. Triggered and automatic activity in the canine coronary sinus. Circ Res 1977; 41:434.
- KILLIP T, GAULT JH. MODE OF ONSET OF ATRIAL FIBRILLATION IN MAN. Am Heart J 1965; 70:172.
- Vincenti A, Brambilla R, Fumagalli MG, et al. Onset mechanism of paroxysmal atrial fibrillation detected by ambulatory Holter monitoring. Europace 2006; 8:204.
- Davis MJ, Hockings BE, el Dessouky MA, et al. Cigarette smoking and ventricular arrhythmia in coronary heart disease. Am J Cardiol 1984; 54:282.
- Ettinger PO, Wu CF, De La Cruz C Jr, et al. Arrhythmias and the "Holiday Heart": alcohol-associated cardiac rhythm disorders. Am Heart J 1978; 95:555.
- Dobmeyer DJ, Stine RA, Leier CV, et al. The arrhythmogenic effects of caffeine in human beings. N Engl J Med 1983; 308:814.
- Bittar G, Friedman HS. The arrhythmogenicity of theophylline. A multivariate analysis of clinical determinants. Chest 1991; 99:1415.
- Sessler CN, Cohen MD. Cardiac arrhythmias during theophylline toxicity. A prospective continuous electrocardiographic study. Chest 1990; 98:672.
- Rechavia E, Strasberg B, Mager A, et al. The incidence of atrial arrhythmias during inferior wall myocardial infarction with and without right ventricular involvement. Am Heart J 1992; 124:387.
- Zoni Berisso M, Ferroni A, De Caro E, et al. Clinical significance of supraventricular tachyarrhythmias after acute myocardial infarction. Eur Heart J 1986; 7:743.
- Bunch TJ, Chandrasekaran K, Gersh BJ, et al. The prognostic significance of exercise-induced atrial arrhythmias. J Am Coll Cardiol 2004; 43:1236.
- Ramsdale DR, Arumugam N, Singh SS, et al. Holter monitoring in patients with mitral stenosis and sinus rhythm. Eur Heart J 1987; 8:164.
- Lazzeroni E, Domenicucci S, Finardi A, et al. Severity of arrhythmias and extent of hypertrophy in hypertrophic cardiomyopathy. Am Heart J 1989; 118:734.
- Bennett MA, Pentecost BL. The pattern of onset and spontaneous cessation of atrial fibrillation in man. Circulation 1970; 41:981.
- Durrer D, Schoo L, Schuilenburg RM, Wellens HJ. The role of premature beats in the initiation and the termination of supraventricular tachycardia in the Wolff-Parkinson-White syndrome. Circulation 1967; 36:644.
- Nallasivan M, Appel RA, Welch WJ, Bauernfeind RA. Ventricular tachycardia due to bundle branch reentry: induction by spontaneous atrial premature beats. Am Heart J 1988; 116:552.
- Berman ND. Ventricular tachycardia initiated by both normally and aberrantly conducted atrial premature beats. Pacing Clin Electrophysiol 1980; 3:519.
- MOE GK, MENDEZ C, HAN J. ABERRANT A-V IMPULSE PROPAGATION IN THE DOG HEART: A STUDY OF FUNCTIONAL BUNDLE BRANCH BLOCK. Circ Res 1965; 16:261.
- Batsford WP, Akhtar M, Caracta AR, et al. Effect of atrial stimulation site on the electrophysiological properties of the atrioventricular node in man. Circulation 1974; 50:283.
- Carbone V, Marafioti V, Oreto G. An unusual narrow QRS complex tachycardia: what is the mechanism? Ann Noninvasive Electrocardiol 2015; 20:94.
- Arif M, Laidlaw JC, Oshrain C, et al. A randomized, double-blind, parallel group comparison of disopyramide phosphate and quinidine in patients with cardiac arrhythmias. Angiology 1983; 34:393.
- Carrasco HA, Vicuña AV, Molina C, et al. Effect of low oral doses of disopyramide and amiodarone on ventricular and atrial arrhythmias of chagasic patients with advanced myocardial damage. Int J Cardiol 1985; 9:425.
- Coumel P, Leclercq JF, Assayag P. European experience with the antiarrhythmic efficacy of propafenone for supraventricular and ventricular arrhythmias. Am J Cardiol 1984; 54:60D.
- Haïssaguerre M, Jaïs P, Shah DC, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998; 339:659.
- Haïssaguerre M, Shah DC, Jaïs P, et al. Electrophysiological breakthroughs from the left atrium to the pulmonary veins. Circulation 2000; 102:2463.
- Oral H, Knight BP, Tada H, et al. Pulmonary vein isolation for paroxysmal and persistent atrial fibrillation. Circulation 2002; 105:1077.
- Yamada T, Murakami Y, Okada T, et al. Electroanatomic mapping in the catheter ablation of premature atrial contractions with a non-pulmonary vein origin. Europace 2008; 10:1320.
- Yamane T, Date T, Kanzaki Y, et al. Behavior of atrial ectopic beats before and after pulmonary vein isolation in patients with atrial fibrillation: a reduction in the number and arrhythmogenicity of ectopic firings. Heart Rhythm 2006; 3:1421.
- Brooks AG, Rangnekar G, Ganesan AN, et al. Characteristics of ectopic triggers associated with paroxysmal and persistent atrial fibrillation: evidence for a changing role. Heart Rhythm 2012; 9:1367.
- Jaïs P, Hocini M, Macle L, et al. Distinctive electrophysiological properties of pulmonary veins in patients with atrial fibrillation. Circulation 2002; 106:2479.
- Chong BH, Pong V, Lam KF, et al. Frequent premature atrial complexes predict new occurrence of atrial fibrillation and adverse cardiovascular events. Europace 2012; 14:942.
- Dewland TA, Vittinghoff E, Mandyam MC, et al. Atrial ectopy as a predictor of incident atrial fibrillation: a cohort study. Ann Intern Med 2013; 159:721.
- Inohara T, Kohsaka S, Okamura T, et al. Long-term outcome of healthy participants with atrial premature complex: a 15-year follow-up of the NIPPON DATA 90 cohort. PLoS One 2013; 8:e80853.
- Qureshi W, Shah AJ, Salahuddin T, Soliman EZ. Long-term mortality risk in individuals with atrial or ventricular premature complexes (results from the Third National Health and Nutrition Examination Survey). Am J Cardiol 2014; 114:59.
- Suzuki S, Sagara K, Otsuka T, et al. Usefulness of frequent supraventricular extrasystoles and a high CHADS2 score to predict first-time appearance of atrial fibrillation. Am J Cardiol 2013; 111:1602.
- Hashimoto M, Yamauchi A, Inoue S. Premature atrial contraction as a predictor of postoperative atrial fibrillation. Asian Cardiovasc Thorac Ann 2015; 23:153.
- Engstrom G, Hedblad B, Juul-Moller S, et al. Cardiac arrhythmias and stroke: increased risk in men with high frequency of atrial ectopic beats. Stroke 2001; 32:1443.
- Binici Z, Intzilakis T, Nielsen OW, et al. Excessive supraventricular ectopic activity and increased risk of atrial fibrillation and stroke. Circulation 2010; 121:1904.
- Ofoma U, He F, Shaffer ML, et al. Premature cardiac contractions and risk of incident ischemic stroke. J Am Heart Assoc 2012; 1:e002519.
- Kochhäuser S, Dechering DG, Dittrich R, et al. Supraventricular premature beats and short atrial runs predict atrial fibrillation in continuously monitored patients with cryptogenic stroke. Stroke 2014; 45:884.
- Weber-Krüger M, Gröschel K, Mende M, et al. Excessive supraventricular ectopic activity is indicative of paroxysmal atrial fibrillation in patients with cerebral ischemia. PLoS One 2013; 8:e67602.
- Wallmann D, Tüller D, Wustmann K, et al. Frequent atrial premature beats predict paroxysmal atrial fibrillation in stroke patients: an opportunity for a new diagnostic strategy. Stroke 2007; 38:2292.
- Cheriyath P, He F, Peters I, et al. Relation of atrial and/or ventricular premature complexes on a two-minute rhythm strip to the risk of sudden cardiac death (the Atherosclerosis Risk in Communities [ARIC] study). Am J Cardiol 2011; 107:151.
- CLINICAL MANIFESTATIONS
- Physical examination
- - ECG findings with APBs
- - ECG findings with JPBs
- - Ambulatory monitoring
- EP testing
- Medical therapy
- Catheter ablation
- SUMMARY AND RECOMMENDATIONS