Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Ventricular premature beats

Antonis S Manolis, MD
Section Editor
Hugh Calkins, MD
Deputy Editor
Brian C Downey, MD, FACC


Ventricular premature beats (VPBs), also referred to as ventricular premature complexes, premature ventricular beats, premature ventricular complexes, or ventricular extrasystoles, are triggered from the ventricular myocardium in a variety of situations. VPBs are common 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 VPBs will be presented here. A discussion of supraventricular premature beats is presented separately. (See "Supraventricular premature beats".)


Lown's grading of VPBs into six categories was initially proposed as a prognostic classification, but it has become clear over the years that this pertains only to acute myocardial infarction and ischemia and bears no prognostic relevance in other situations [1]. Prognosis relates only to the underlying structural heart disease and the degree of any left ventricular dysfunction, not to the complexity of the VPBs. Nevertheless, it has served as a descriptive reference point of communicating the complexity of ventricular ectopy. The following six grades have been included in this type of classification:

Grade 0 – No VPBs

Grade I – Unifocal and infrequent VPBs; <30 VPBs per hour


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: May 2017. | This topic last updated: May 10, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Lown B, Wolf M. Approaches to sudden death from coronary heart disease. Circulation 1971; 44:130.
  2. HISS RG, LAMB LE. Electrocardiographic findings in 122,043 individuals. Circulation 1962; 25:947.
  3. Jouven X, Zureik M, Desnos M, et al. Long-term outcome in asymptomatic men with exercise-induced premature ventricular depolarizations. N Engl J Med 2000; 343:826.
  4. Sobotka PA, Mayer JH, Bauernfeind RA, et al. Arrhythmias documented by 24-hour continuous ambulatory electrocardiographic monitoring in young women without apparent heart disease. Am Heart J 1981; 101:753.
  5. Brodsky M, Wu D, Denes P, et al. Arrhythmias documented by 24 hour continuous electrocardiographic monitoring in 50 male medical students without apparent heart disease. Am J Cardiol 1977; 39:390.
  6. Simpson RJ Jr, Cascio WE, Schreiner PJ, et al. Prevalence of premature ventricular contractions in a population of African American and white men and women: the Atherosclerosis Risk in Communities (ARIC) study. Am Heart J 2002; 143:535.
  7. Glasser SP, Clark PI, Applebaum HJ. Occurrence of frequent complex arrhythmias detected by ambulatory monitoring: findings in an apparently healthy asymptomatic elderly population. Chest 1979; 75:565.
  8. Yang J, Dudum R, Mandyam MC, Marcus GM. Characteristics of unselected high-burden premature ventricular contraction patients. Pacing Clin Electrophysiol 2014; 37:1671.
  9. McLenachan JM, Henderson E, Morris KI, Dargie HJ. Ventricular arrhythmias in patients with hypertensive left ventricular hypertrophy. N Engl J Med 1987; 317:787.
  10. Eldar M, Sievner Z, Goldbourt U, et al. Primary ventricular tachycardia in acute myocardial infarction: clinical characteristics and mortality. The SPRINT Study Group. Ann Intern Med 1992; 117:31.
  11. Heidbüchel H, Tack J, Vanneste L, et al. Significance of arrhythmias during the first 24 hours of acute myocardial infarction treated with alteplase and effect of early administration of a beta-blocker or a bradycardiac agent on their incidence. Circulation 1994; 89:1051.
  12. Teerlink JR, Jalaluddin M, Anderson S, et al. Ambulatory ventricular arrhythmias in patients with heart failure do not specifically predict an increased risk of sudden death. PROMISE (Prospective Randomized Milrinone Survival Evaluation) Investigators. Circulation 2000; 101:40.
  13. Le VV, Mitiku T, Hadley D, et al. Rest premature ventricular contractions on routine ECG and prognosis in heart failure patients. Ann Noninvasive Electrocardiol 2010; 15:56.
  14. Agarwal V, Vittinghoff E, Whitman IR, et al. Relation Between Ventricular Premature Complexes and Incident Heart Failure. Am J Cardiol 2017; 119:1238.
  15. Jeserich M, Merkely B, Olschewski M, et al. Patients with exercise-associated ventricular ectopy present evidence of myocarditis. J Cardiovasc Magn Reson 2015; 17:100.
  16. Adabag AS, Casey SA, Kuskowski MA, et al. Spectrum and prognostic significance of arrhythmias on ambulatory Holter electrocardiogram in hypertrophic cardiomyopathy. J Am Coll Cardiol 2005; 45:697.
  17. Zuchinali P, Ribeiro PA, Pimentel M, et al. Effect of caffeine on ventricular arrhythmia: a systematic review and meta-analysis of experimental and clinical studies. Europace 2016; 18:257.
  18. Dixit S, Stein PK, Dewland TA, et al. Consumption of Caffeinated Products and Cardiac Ectopy. J Am Heart Assoc 2016; 5.
  19. Dogan M, Yiginer O, Uz O, et al. The Effects of Female Sex Hormones on Ventricular Premature Beats and Repolarization Parameters in Physiological Menstrual Cycle. Pacing Clin Electrophysiol 2016; 39:418.
  20. Tran CT, Calkins H. Premature ventricular contraction-induced cardiomyopathy: an emerging entity. Expert Rev Cardiovasc Ther 2016; 14:1227.
  21. Wolff GA, Veith F, Lown B. A vulnerable period for ventricular tachycardia following myocardial infarction. Cardiovasc Res 1968; 2:111.
  22. de Soyza N, Bissett JK, Kane JJ, et al. Ectopic ventricular prematurity and its relationship to ventricular tachycardia in acute myocardial infarction in man. Circulation 1974; 50:529.
  23. Roberts R, Ambos HD, Loh CW, Sobel BE. Initiation of repetitive ventricular depolarizations by relatively late premature complexes in patients with acute myocardial infarction. Am J Cardiol 1978; 41:678.
  24. Nam GB, Ko KH, Kim J, et al. Mode of onset of ventricular fibrillation in patients with early repolarization pattern vs. Brugada syndrome. Eur Heart J 2010; 31:330.
  25. Yan GX, Antzelevitch C. Cellular basis for the Brugada syndrome and other mechanisms of arrhythmogenesis associated with ST-segment elevation. Circulation 1999; 100:1660.
  26. Viskin S, Lesh MD, Eldar M, et al. Mode of onset of malignant ventricular arrhythmias in idiopathic ventricular fibrillation. J Cardiovasc Electrophysiol 1997; 8:1115.
  27. Morganroth J, Michelson EL, Horowitz LN, et al. Limitations of routine long-term electrocardiographic monitoring to assess ventricular ectopic frequency. Circulation 1978; 58:408.
  28. Michelson EL, Morganroth J. Spontaneous variability of complex ventricular arrhythmias detected by long-term electrocardiographic recording. Circulation 1980; 61:690.
  29. Raeder EA, Hohnloser SH, Graboys TB, et al. Spontaneous variability and circadian distribution of ectopic activity in patients with malignant ventricular arrhythmia. J Am Coll Cardiol 1988; 12:656.
  30. 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.
  31. Pratt CM, Slymen DJ, Wierman AM, et al. Analysis of the spontaneous variability of ventricular arrhythmias: consecutive ambulatory electrocardiographic recordings of ventricular tachycardia. Am J Cardiol 1985; 56:67.
  32. 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.
  33. DeBusk RF, Davidson DM, Houston N, Fitzgerald J. Serial ambulatory electrocardiography and treadmill exercise testing after uncomplicated myocardial infarction. Am J Cardiol 1980; 45:547.
  34. Lichstein E, Morganroth J, Harrist R, Hubble E. Effect of propranolol on ventricular arrhythmia. The beta-blocker heart attack trial experience. Circulation 1983; 67:I5.
  35. González-Fernández RA, Rivera M, Rodríguez PJ, et al. Prevalence of ectopic ventricular activity after left ventricular mass regression. Am J Hypertens 1993; 6:308.
  36. Ng GA. Treating patients with ventricular ectopic beats. Heart 2006; 92:1707.
  37. Echt DS, Liebson PR, Mitchell LB, et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial. N Engl J Med 1991; 324:781.
  38. Waldo AL, Camm AJ, deRuyter H, et al. Effect of d-sotalol on mortality in patients with left ventricular dysfunction after recent and remote myocardial infarction. The SWORD Investigators. Survival With Oral d-Sotalol. Lancet 1996; 348:7.
  39. Podrid PJ, Lampert S, Graboys TB, et al. Aggravation of arrhythmia by antiarrhythmic drugs--incidence and predictors. Am J Cardiol 1987; 59:38E.
  40. Lauribe P, Shah D, Jaïs P, et al. Radiofrequency catheter ablation of drug refractory symptomatic ventricular ectopy: short- and long-term results. Pacing Clin Electrophysiol 1999; 22:783.
  41. Lamba J, Redfearn DP, Michael KA, et al. Radiofrequency catheter ablation for the treatment of idiopathic premature ventricular contractions originating from the right ventricular outflow tract: a systematic review and meta-analysis. Pacing Clin Electrophysiol 2014; 37:73.
  42. Anastasiou-Nana MI, Gilbert EM, Miller RH, et al. Usefulness of d, I sotalol for suppression of chronic ventricular arrhythmias. Am J Cardiol 1991; 67:511.
  43. Cairns JA, Connolly SJ, Roberts R, Gent M. Randomised trial of outcome after myocardial infarction in patients with frequent or repetitive ventricular premature depolarisations: CAMIAT. Canadian Amiodarone Myocardial Infarction Arrhythmia Trial Investigators. Lancet 1997; 349:675.
  44. Julian DG, Camm AJ, Frangin G, et al. Randomised trial of effect of amiodarone on mortality in patients with left-ventricular dysfunction after recent myocardial infarction: EMIAT. European Myocardial Infarct Amiodarone Trial Investigators. Lancet 1997; 349:667.
  45. Singh SN, Fletcher RD, Fisher SG, et al. Amiodarone in patients with congestive heart failure and asymptomatic ventricular arrhythmia. Survival Trial of Antiarrhythmic Therapy in Congestive Heart Failure. N Engl J Med 1995; 333:77.
  46. Chadda K, Goldstein S, Byington R, Curb JD. Effect of propranolol after acute myocardial infarction in patients with congestive heart failure. Circulation 1986; 73:503.
  47. Hasdemir C, Ulucan C, Yavuzgil O, et al. Tachycardia-induced cardiomyopathy in patients with idiopathic ventricular arrhythmias: the incidence, clinical and electrophysiologic characteristics, and the predictors. J Cardiovasc Electrophysiol 2011; 22:663.
  48. Satish OS, Yeh KH, Wen MS, Wang CC. Premature ventricular contraction-induced concealed mechanical bradycardia and dilated cardiomyopathy:. J Cardiovasc Electrophysiol 2005; 16:88.
  49. Chugh SS, Shen WK, Luria DM, Smith HC. First evidence of premature ventricular complex-induced cardiomyopathy: a potentially reversible cause of heart failure. J Cardiovasc Electrophysiol 2000; 11:328.
  50. Baman TS, Lange DC, Ilg KJ, et al. Relationship between burden of premature ventricular complexes and left ventricular function. Heart Rhythm 2010; 7:865.
  51. Takemoto M, Yoshimura H, Ohba Y, et al. Radiofrequency catheter ablation of premature ventricular complexes from right ventricular outflow tract improves left ventricular dilation and clinical status in patients without structural heart disease. J Am Coll Cardiol 2005; 45:1259.
  52. Efremidis M, Letsas KP, Sideris A, Kardaras F. Reversal of premature ventricular complex-induced cardiomyopathy following successful radiofrequency catheter ablation. Europace 2008; 10:769.
  53. Zhong L, Lee YH, Huang XM, et al. Relative efficacy of catheter ablation vs antiarrhythmic drugs in treating premature ventricular contractions: a single-center retrospective study. Heart Rhythm 2014; 11:187.
  54. Taieb JM, Maury P, Shah D, et al. Reversal of dilated cardiomyopathy by the elimination of frequent left or right premature ventricular contractions. J Interv Card Electrophysiol 2007; 20:9.
  55. Wijnmaalen AP, Delgado V, Schalij MJ, et al. Beneficial effects of catheter ablation on left ventricular and right ventricular function in patients with frequent premature ventricular contractions and preserved ejection fraction. Heart 2010; 96:1275.
  56. Yarlagadda RK, Iwai S, Stein KM, et al. Reversal of cardiomyopathy in patients with repetitive monomorphic ventricular ectopy originating from the right ventricular outflow tract. Circulation 2005; 112:1092.
  57. Yokokawa M, Good E, Crawford T, et al. Recovery from left ventricular dysfunction after ablation of frequent premature ventricular complexes. Heart Rhythm 2013; 10:172.
  58. European Heart Rhythm Association, Heart Rhythm Society, Zipes DP, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol 2006; 48:e247.
  59. Haïssaguerre M, Shoda M, Jaïs P, et al. Mapping and ablation of idiopathic ventricular fibrillation. Circulation 2002; 106:962.
  60. Priori SG, Blomström-Lundqvist C, Mazzanti A, et al. 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J 2015; 36:2793.
  61. Lip GY, Heinzel FR, Gaita F, et al. European Heart Rhythm Association/Heart Failure Association joint consensus document on arrhythmias in heart failure, endorsed by the Heart Rhythm Society and the Asia Pacific Heart Rhythm Society. Europace 2016; 18:12.
  62. Massing MW, Simpson RJ Jr, Rautaharju PM, et al. Usefulness of ventricular premature complexes to predict coronary heart disease events and mortality (from the Atherosclerosis Risk In Communities cohort). Am J Cardiol 2006; 98:1609.
  63. Engel G, Cho S, Ghayoumi A, et al. Prognostic significance of PVCs and resting heart rate. Ann Noninvasive Electrocardiol 2007; 12:121.
  64. 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.
  65. Lee V, Hemingway H, Harb R, et al. The prognostic significance of premature ventricular complexes in adults without clinically apparent heart disease: a meta-analysis and systematic review. Heart 2012; 98:1290.
  66. Ataklte F, Erqou S, Laukkanen J, Kaptoge S. Meta-analysis of ventricular premature complexes and their relation to cardiac mortality in general populations. Am J Cardiol 2013; 112:1263.
  67. Lin CY, Chang SL, Lin YJ, et al. An observational study on the effect of premature ventricular complex burden on long-term outcome. Medicine (Baltimore) 2017; 96:e5476.
  68. Dukes JW, Dewland TA, Vittinghoff E, et al. Ventricular Ectopy as a Predictor of Heart Failure and Death. J Am Coll Cardiol 2015; 66:101.
  69. Abdalla IS, Prineas RJ, Neaton JD, et al. Relation between ventricular premature complexes and sudden cardiac death in apparently healthy men. Am J Cardiol 1987; 60:1036.
  70. Barrett PA, Peter CT, Swan HJ, et al. The frequency and prognostic significance of electrocardiographic abnormalities in clinically normal individuals. Prog Cardiovasc Dis 1981; 23:299.
  71. Elkon KB, Swerdlow TA, Myburgh DP. Persistent ventricular ectopic beats: a long-term study. S Afr Med J 1977; 52:564.
  72. Rodstein M, Wolloch L, Gubner RS. Mortality study of the significance of extrasystoles in an insured population. Circulation 1971; 44:617.
  73. Kennedy HL, Whitlock JA, Sprague MK, et al. Long-term follow-up of asymptomatic healthy subjects with frequent and complex ventricular ectopy. N Engl J Med 1985; 312:193.
  74. Bikkina M, Larson MG, Levy D. Prognostic implications of asymptomatic ventricular arrhythmias: the Framingham Heart Study. Ann Intern Med 1992; 117:990.
  75. Sajadieh A, Nielsen OW, Rasmussen V, et al. Ventricular arrhythmias and risk of death and acute myocardial infarction in apparently healthy subjects of age >or=55 years. Am J Cardiol 2006; 97:1351.
  76. Lin CY, Chang SL, Lin YJ, et al. Long-term outcome of multiform premature ventricular complexes in structurally normal heart. Int J Cardiol 2015; 180:80.
  77. Kim RJ, Iwai S, Markowitz SM, et al. Clinical and electrophysiological spectrum of idiopathic ventricular outflow tract arrhythmias. J Am Coll Cardiol 2007; 49:2035.
  78. Podrid PJ, Fogel RI, Fuchs TT. Ventricular arrhythmia in congestive heart failure. Am J Cardiol 1992; 69:82G.
  79. Smilde TD, van Veldhuisen DJ, van den Berg MP. Prognostic value of heart rate variability and ventricular arrhythmias during 13-year follow-up in patients with mild to moderate heart failure. Clin Res Cardiol 2009; 98:233.
  80. Vazquez R, Bayes-Genis A, Cygankiewicz I, et al. The MUSIC Risk score: a simple method for predicting mortality in ambulatory patients with chronic heart failure. Eur Heart J 2009; 30:1088.
  81. Bhonsale A, James CA, Tichnell C, et al. Incidence and predictors of implantable cardioverter-defibrillator therapy in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy undergoing implantable cardioverter-defibrillator implantation for primary prevention. J Am Coll Cardiol 2011; 58:1485.
  82. Duffee DF, Shen WK, Smith HC. Suppression of frequent premature ventricular contractions and improvement of left ventricular function in patients with presumed idiopathic dilated cardiomyopathy. Mayo Clin Proc 1998; 73:430.
  83. Gopinathannair R, Etheridge SP, Marchlinski FE, et al. Arrhythmia-Induced Cardiomyopathies: Mechanisms, Recognition, and Management. J Am Coll Cardiol 2015; 66:1714.
  84. Lee AK, Deyell MW. Premature ventricular contraction-induced cardiomyopathy. Curr Opin Cardiol 2016; 31:1.
  85. Morshedi-Meibodi A, Evans JC, Levy D, et al. Clinical correlates and prognostic significance of exercise-induced ventricular premature beats in the community: the Framingham Heart Study. Circulation 2004; 109:2417.
  86. Sabbag A, Sidi Y, Kivity S, et al. Obesity and exercise-induced ectopic ventricular arrhythmias in apparently healthy middle aged adults. Eur J Prev Cardiol 2016; 23:511.
  87. Mora S, Redberg RF, Cui Y, et al. Ability of exercise testing to predict cardiovascular and all-cause death in asymptomatic women: a 20-year follow-up of the lipid research clinics prevalence study. JAMA 2003; 290:1600.
  88. Lee V, Perera D, Lambiase P. Prognostic significance of exercise-induced premature ventricular complexes: a systematic review and meta-analysis of observational studies. Heart Asia 2017; 9:14.
  89. Kim J, Kwon M, Chang J, et al. Meta-Analysis of Prognostic Implications of Exercise-Induced Ventricular Premature Complexes in the General Population. Am J Cardiol 2016; 118:725.
  90. Udall JA, Ellestad MH. Predictive implications of ventricular premature contractions associated with treadmill stress testing. Circulation 1977; 56:985.
  91. Califf RM, McKinnis RA, McNeer JF, et al. Prognostic value of ventricular arrhythmias associated with treadmill exercise testing in patients studied with cardiac catheterization for suspected ischemic heart disease. J Am Coll Cardiol 1983; 2:1060.
  92. Frolkis JP, Pothier CE, Blackstone EH, Lauer MS. Frequent ventricular ectopy after exercise as a predictor of death. N Engl J Med 2003; 348:781.
  93. Dewey FE, Kapoor JR, Williams RS, et al. Ventricular arrhythmias during clinical treadmill testing and prognosis. Arch Intern Med 2008; 168:225.
  94. Agarwal SK, Heiss G, Rautaharju PM, et al. Premature ventricular complexes and the risk of incident stroke: the Atherosclerosis Risk In Communities (ARIC) Study. Stroke 2010; 41:588.
  95. Agarwal SK, Chao J, Peace F, et al. Premature ventricular complexes on screening electrocardiogram and risk of ischemic stroke. Stroke 2015; 46:1365.