Dr. Kulick received his undergraduate and medical degrees from the University of Southern California, School of Medicine. He performed his residency in internal medicine at the Harbor-University of California Los Angeles Medical Center and a fellowship in the section of cardiology at the Los Angeles County-University of Southern California Medical Center. He is board certified in Internal Medicine and Cardiology.
Dr. Lee was born in Shanghai, China, and received his college and medical training in the United States. He is fluent in English and three Chinese dialects. He graduated with chemistry departmental honors from Harvey Mudd College. He was appointed president of AOA society at UCLA School of Medicine. He underwent internal medicine residency and gastroenterology fellowship training at Cedars Sinai Medical Center.
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
What are the dangers of premature ventricular contractions?
Premature ventricular contractions in healthy
individuals without high blood pressure and heart diseases do not pose any
health risks. Premature ventricular contractions in patients with heart diseases
(heart attacks, heart failure, diseases of the heart valves)
may be associated with
increased risks of developing ventricular tachycardia. Ventricular tachycardia
is a sustained run of rapid ventricular contractions. Ventricular tachycardia is
life-threatening because: 1) it occurs suddenly with no prior warning, and 2) it
frequently develops into ventricular fibrillation. Ventricular fibrillation is a chaotic rhythm where the
ventricles quiver rapidly in a purposeless fashion. The heart with ventricular
fibrillation cannot pump blood effectively to the brain
and the rest of the body. If untreated, ventricular fibrillation can be fatal
within minutes. An estimated 250,000 Americans die in this way each year.
Many doctors believe that premature ventricular contractions do not necessarily cause ventricular tachycardias or ventricular fibrillations. Instead, premature ventricular contractions may be merely indicators (symptoms) of serious heart diseases or other serious conditions
such as hypokalemia, hypoxia, and on-going heart damage from heart attacks, or
medications such as digoxin
and
aminophylline toxicity. It must be emphasized that many
premature ventricular contractions are harmless (benign) and not associated with structural heart disease. If the work up for underlying heart disease is unrevealing, the patient can be assured that their prognosis is excellent.
How is premature ventricular contraction diagnosed?
There are two aspects in the diagnosis of premature
ventricular contractions; detecting them, and diagnosing the underlying causes.
Electrocardiograms (ECG EKG) and Holter monitors are used to diagnose premature ventricular
contractions. EKGs, blood tests, echocardiograms,
and cardiac stress tests are used to
determine the underling causes of premature ventricular contractions.
Electrocardiogram (EKG, ECG)
An electrocardiogram (EKG,
ECG) is a brief recording of the
heart's electrical discharges. EKGs can be performed in the doctors' offices,
clinics, and hospital emergency rooms. Doctors frequently ask for a rhythm strip
(a prolonged EKG recording) to be performed at the same time as EKG to increase
the chances of detecting premature ventricular contractions and other abnormal rhythms. The premature ventricular contractions are easy to recognize on EKG
and rhythms strips, provided premature ventricular contractions occur during the recording. EKG may also
demonstrate other problems such as heart attacks, hypokalemia, digoxin toxicity,
heart muscle thickening (hypertrophy) due to long term high blood pressure.
Holter monitor
A standard EKG and a rhythm strip performed at the time
of a visit to the doctor's office may not detect the premature ventricular
contractions because they may not be occurring at that moment.
Holter monitoring is then
necessary to detect the premature ventricular contractions in these patients with heart palpitations. A Holter
monitor is a continuous recording of the heart's rhythm for 24 hours. Holter
monitoring can be used diagnose premature ventricular contractions as well as other
heart rhythm abnormalities
such as atrial fibrillation, atrial flutter, and ventricular tachycardias.
Since more than 50% of middle aged men
can have premature ventricular contractions during Holter monitoring, not all
premature ventricular contractions found during Holter
monitoring are clinically important. Doctors interpreting the Holter monitoring
studies must take into account the patient's medical history in determining the
importance of Holter monitor findings.
In patients with infrequent symptoms an event marker may be used in lieu of a Holter monitor as this can be worn for up to 30 days.
Echocardiography
Echocardiography uses
ultrasound waves to produce images of the heart's
chambers and valves and the lining around the heart (pericardium).
Echocardiography is useful in measuring the size of the heart chambers, the
forcefulness of heart ventricle contractions, the thickness of the heart
muscles, and the functioning of the heart valves. Echocardiography is therefore
useful in diagnosing conditions that can cause premature ventricular
contractions such as:
Mitral valve prolapse: Echocardiography can detect and measure the severity
of mitral valve prolapse
and other valvular diseases.
Muscle hypertrophy: Echocardiography can detect heart muscle hypertrophy
(thickening of heart muscle) as a result of long term high blood pressure.
Heart muscle damage: Echocardiography can measure the extent of heart
muscle damage from heart attacks or cardiomyopathy.
Ejection fraction: Echocardiography can be
used to calculate the ejection fraction of the left ventricle. Ejection fraction
is a measure (estimate) of the amount of blood pumped during each contraction of
the ventricle. Heart ventricles extensively weakened by heart attacks or
cardiomyopathy will have low ejection fractions. Patients with low ejection
fractions have higher risks of developing life threatening ventricular
tachycardias and fibrillations than patients with normal ejection fractions.
Exercise cardiac stress test
(treadmill stress test)
Exercise cardiac stress testing (ECST) is the most
widely used cardiac stress test. The patient exercises on a treadmill according
to a standardized protocol with progressive increases in the speed and elevation of the treadmill
(typically changing at three minute intervals). During the ECST, the patient's
electrocardiogram (EKG), heart rate, heart
rhythm, and blood pressure are continuously monitored. If a coronary arterial
blockage results in decreased blood flow to a part of the heart during exercise,
certain changes may be observed in the EKG, including increase in premature
ventricular contractions and development of ventricular
tachycardias.
Adjuncts to ECST (stress echo and nuclear imaging)
Another supplement to the routine ECST is stress
echocardiography. During stress echocardiography, the sound waves of ultrasound
are used to produce images of the heart at rest and at the peak of exercise. In
a heart with normal blood supply, all segments of the left ventricle (the major
pumping chamber of
the heart) exhibit enhanced contractions of the heart muscle during peak
exercise. Conversely, in the setting of cardiovascular disease, if a segment of the left ventricle does not receive optimal blood
flow during exercise, that segment will demonstrate reduced contractions of
heart muscle relative to the rest of the heart on the exercise echocardiogram.
Stress echocardiography is very useful in enhancing the interpretation of the
ECST, and can be used to exclude the presence of significant cardiovascular
disease in patients suspected of having a "false-positive" ECST. Alternatively, nuclear imaging may be used as an adjunct to ECST and may be even more sensitive in noninvasively detecting underlying coronary artery disease.
Blood tests in diagnosing causes of premature ventricular contractions
Blood tests for diagnosing
conditions that can cause premature ventricular contractions include:
blood drug levels can be performed to detect digoxin
and aminophylline drug toxicity
or thyroid levels, for example, an
overactive thyroid may
result in premature ventricular contractions;
blood oxygenation
(oximetry) can be measured to detect hypoxia;
blood tests can be performed to detect illicit drugs,
such as amphetamine abuse; and
blood levels of cardiac enzymes [creatine phosphokinase (CPK), troponins
(regulatory proteins)] can be performed to assess for heart muscle
damage as a result of heart attacks.
Low blood pressure, also referred to as hypotension, is blood pressure that is so low that it causes symptoms or signs due to the low flow of blood through the arteries and veins. Some of the symptoms of low blood pressure include light-headedness, dizziness, or even fainting if not enough blood is getting to the brain. Diseases and medications can also cause low blood pressure. When the flow of blood is too low to deliver enough oxygen and nutrients to vital organs such as the brain, heart, and kidneys; the organs do not function normally and may be permanently damaged.
Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to meet the body's needs. A poor blood supply resulting from congestive heart failure may cause the body's organ systems to fail, leading to a weakened heart muscle and fluid accumulation in the lungs and body tissue. There are many diseases that can impair pumping efficiency and symptoms of congestive heart failure including fatigue, diminished exercise capacity, shortness of breath, and swelling. Treatments include lifestyle modifications, medications, heart transplant, and therapy.
High blood pressure, also known as hypertension, is a repeatedly
elevated blood pressure exceeding 140 over 90 mmHg -- a systolic pressure above
140 with a diastolic pressure above 90. There are two causes of high blood pressure, primary and secondary. Primary high blood pressure is much more common that secondary and its basic causes or underlying defects are not always known. It is known that a diet high in salt increases the risk for high blood pressure, as well as high cholesterol. Genetic factors are also a primary cause. Secondary high blood pressure is generally caused by another condition such as renal hypertension, tumors, and other conditions. Treatment for high blood pressure is generally lifestyle changes and if necessary, diet.
Dizziness is a symptom that is often applies to a variety of sensations including lightheadedness and vertigo. Causes of dizziness include low blood pressure, heart problems, anemia, dehydration, and more. Treatment of dizziness depends on the cause.
Hyperthyroidism is an excess of thyroid hormone resulting from an overactive thyroid gland. Symptoms can include increased heart rate, weight
loss, depression, and cognitive slowing. Treatment is by medication, the use of
radioactive iodine, thyroid surgery, or reducing the dose of thyroid hormone.
Palpitations are unpleasant sensations of irregular and/or forceful beating of the heart. Palpitations can be relieved in many patients by stress reduction, stopping cigarettes, and reduction of caffeine and alcohol.
Fainting, also referred to as blacking out, syncope, or temporary loss of consciousness has many causes. Often a person will have signs or symptoms prior to the fainting episode. Diagnosis and treatment depends upon the cause of the fainting or syncope episode.
Heart attack happens when a blood clot completely obstructs a coronary
artery supplying blood to the heart muscle. A heart attack can cause chest pain, heart failure, and electrical
instability of the heart.
COPD (chronic obstructive pulmonary disease) is a disorder that persistently obstructs bronchial airflow. COPD mainly involves three related conditions, chronic bronchitis, chronic asthma, and emphysema. Symptoms of COPD include chronic cough, shortness of breath, frequent respiratory infections, wheezing, morning headaches, and pulmonary hypertension. Treatment of COPD is focused on the related condition(s).
Mitral valve prolapse (MVP) is also also known as "click murmur syndrome" and "Barlow's syndrome." Mitral valve prolapse is the most common heart valve abnormality. Signs and symptoms of mitral valve prolapse include: fatigue, palpitations, chest pain, anxiety, and migraine headaches. Echocardiography is the most useful test for mitral valve prolapse. Most patients do not need any treatment, however, patients with severe prolapse may need treatment.
Potassium is an essential electrolyte necessary for cell function. Low potassium (hypokalemia) may be caused by diarrhea, vomiting, ileostomy, colon polyps, laxative use, diuretics, elevated corticosteroid levels, renal artery stenosis, and renal tubular acidosis, or other medications. Symptoms of low potassium include weakness, aches, and cramps of the muscles. Treatment is dependant upon the cause of the low potassium (hypokalemia).
Emphysema is a progressive disease of the lungs. The primary cause of emphysema is smoking. Alpha 1-antitrypsin deficiency is a rare disorder that has a genetic predisposition to emphysema. Aging, IV drug use, immune deficiencies, and connect tissue illnesses are also risk factors for emphysema. Emphysema is a subtype of COPD (chronic obstructive pulmonary disease, COLD). Symptoms include shortness of breath and wheezing. Management of symptoms may be achieved with medications, quitting smoking, pulmonary rehabilitation, or surgery.
Heart rhythm disorders vary from minor palpitations, premature atrial contractions (PACs), premature ventricular contractions (PVCs), sinus tachycardia, and sinus brachycardia, to abnormal heart rhythms such as tachycardia, ventricular fibrillation, ventricular flutter, atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia (PSVT), Wolf-White-Parkinson syndrome, brachycardia, or heart blocks. Treatment is dependant upon the type of heart rhythm disorder.
Heart disease (coronary artery disease) is caused by a buildup of cholesterol deposits in the coronary arteries. Risk factors for heart disease include smoking, high blood pressure, heredity, diabetes, peripheral artery disease, and obesity. Symptoms include chest pain and shortness of breath. There are a variety of tests used to diagnose coronary artery disease. Treatment includes life-style changes, medications, procedures, or surgery.
Heart valve disease occurs when the heart valves do not work the way they should. Symptoms of valve disease include shortness of breath, weakness or dizziness, discomfort in your chest, palpitations, swelling of your ankles, feet or abdomen, and rapid weight gain.
Myocarditis is an inflammation of the heart muscle and can be caused by a variety of infections, conditions, and viruses. Symptoms of myocarditis include chest pain, shortness of breath, fatigue, and fluid accumulation in the lungs. Treatment mainly involves preventing heart failure with medication and diet, as well as monitoring for heart rhythm abnormalities.
Sudden cardiac arrest is an unexpected, sudden death caused by sudden cardiac arrest (loss of heart function). Causes and risk factors of sudden cardiac arrest include (not inclusive): abnormal heart rhythms (arrhythmias), previous heart attack, coronary artery disease, smoking, high cholesterol, Wolff-Parkinson-White Syndrome, ventricular tachycardia or ventricular fibrillation after a heart attack, congenital heart defects, history of fainting, and heart failure, obesity, diabetes, and drug abuse. Treatment of sudden cardiac arrest is an emergency, and action must be taken immediately.
Heart failure is caused by many conditions including coronary artery disease, heart attack, cardiomyopathy, and conditions that overwork the heart. Symptoms of heart failure include congested lungs, fluid and water retention, dizziness, fatigue and weakness, and rapid or irregular heartbeats.
The heart is a very important organ in the body. It is responsible for continuously pumping oxygen and nutrient-rich blood throughout your body to sustain life. It is a fist-sized muscle that beats (expands and contracts) 100,000 times per day, pumping a total of five or six quarts of blood each minute, or about 2,000 gallons per day.
If you have a COPD such as emphysema, avoiding chronic bronchitis and colds is important to avoid a more severe respiratory infection such as pneumonia. Avoiding cigarette smoking, practice good hygeine, stay away from crowds, and alerting your healthcare provider if you have a sinus infection or cold or cough that becomes worse. Treatment options depend upon the severity of the emphysema, bronchitis, or cold combination.
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