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Extra Beats

There’s a line in Neil Armstrong’s authorized biography, “First Man,” that I totally love. He said, “I believe every human has a finite number of heartbeats. I don’t intend to waste any of mine.” 

There’s no doubt he put his allotted heartbeats to good use and all of us should strive to do the same. By this measure, getting a few extra beats during your lifetime would seem like a great thing, but be careful what you wish for. If your AME catches some extra beats at your next medical exam, the FAA might have a big surprise waiting for you. In the April article on EKGs we talked about “ventricular systole,” the time when the major pumping chambers of the heart beat (contract) to send blood around to your body. Your heart normally beats with a regular rhythm (appropriately known as “normal sinus rhythm”), but sometimes a few extra beats get thrown into the mix. Extra beats have all kinds of different names but the catchall phrase is “extrasystole,” which refers to added heartbeats in the regular cardiac cycle. When the extra beats originate early in the electrical cycle of the heart (and the added impulse comes from the ventricles) they are called “premature ventricular contractions” or the more user-friendly term, “PVCs.” It makes your heart rhythm irregular since the extra beats are out of sync with the rest of the cardiac rhythm. Not all extra beats originate in the ventricles; sometimes the additional heartbeats start in the atria (the small collecting chambers). Those are called “PACs,” for premature atrial contractions, and, except in some special conditions, that’s not an issue health wise or for the FAA. The only reason to make note of PACs is that they can cause your heart rhythm to feel irregular with the same thumping sensation as PVCs.

PVCs are about the most common cardiac arrhythmia (abnormal heart rhythm), and as many as 50-75% of the population have PVCs found on an EKG at some point even in otherwise perfectly healthy individuals. The incidence of PVCs is more common with increasing age, especially after 65. PVCs are also more common in men, taller height, higher blood pressure, stress, physical inactivity, and smokers. When they occur, you might feel PVCs as a little thump in your chest, a skip in the usual rhythm of your heart or a kind of fluttering sensation in your chest or neck. But just as often, it’s about 50/50, you’re likely to have no symptoms and don’t know you’re having PVCs. The standard 12-lead EKG (4 limb leads and 8 “precordial” leads across your chest) lasts about 20-30 seconds and captures around 25-35 heartbeats depending on your heart rate. The number of PVCs found on an EKG is called the PVC “burden,” and the FAA allows only one extra beat on a routine EKG. That means the PVC “burden” the FAA will clear you with is about 2.5% of your cardiac rhythm. That’s a fairly tight standard since the American College of Cardiology refers to a 5% PVC burden as another of those “normal variants” that we talked about in the April article. Normal or not, there are several issues about extra beats that could impact your health and your medical clearance to fly; how many PVCs you have, if there are any symptoms, and, most importantly, why you are having them.

Usually, there’s no need to worry about a few PVCs, and the FAA requires no further evaluation of a pilot when occasional PVCs (one per 30-second EKG strip) are found as long as the candidate is healthy and otherwise asymptomatic. The problem is that all kinds of cardiac maladies can be associated with PVCs, so the issue for you and the FAA is differentiating a few benign extra beats from PVCs that are associated with structural heart disease (SHD). When heart disease is present, symptoms can be more serious like dizziness, prolonged palpitations, chest pain, shortness of breath, syncope, or worse – sudden cardiac arrest. Any of these issues portend a very different concern and clearly require a thorough cardiac evaluation and treatment.

Doing the math, one PVC every 30 seconds means you’re having about 3,000 a day. Most of the cardiology literature considers 5-10% PVC burden “well tolerated” by patients with no structural heart disease and that means, although you won’t get your FAA clearance, your doc won’t get too concerned even if you have up to 12,000 PVCs in 24 hours. But over 10% (“moderate burden”), the issue becomes much more serious for you. It’s not just the number –having any PVCs needs serious consideration and medical management in patients who have had a heart attack, congestive heart failure, valvular heart disease, multiple PVCs in a row (coupling), and PVCs that occur very soon after the last heartbeat (called “R on T phenomenon”). The workup you’ll need starts with a thorough physical exam, and will also include a 24- or 48-hour Holter monitor, which tracks every heartbeat and cardiac echo, and a bunch of lab tests. Your doc might also want to see cardiac magnetic resonance imaging (MRI) and an exercise stress test. If something is found on these tests, you might need further evaluation with a cardiac catheterization to see the anatomy of your coronary arteries and heart structure, or an electrophysiology study (EPS) to map out where the arrhythmia originates and see if PVCs can be induced or sustained. Any need for further cardiac invasive procedures or medications is determined by the results of all of these tests.

There are a bunch of treatments for PVCs, all of which depend on why you’re having them. If it turns out that your PVCs are being generated by a structural heart problem, that issue will need to be corrected to treat the arrhythmia. There are also a variety of medications to treat PVCs such as beta-blockers, calcium and sodium channel blockers, and another medication called Amiodarone (my favorite med) that’s a combination drug. If your PVCs are not related to intrinsic heart disease, you’ll need to make a thorough inventory of your lifestyle, since multiple known causes of PVCs are related to general health choices. As hard as it might be to make big changes in your daily habits, start by reducing your stress level, cut out everything with caffeine, get more exercise and more sleep, eat a healthier diet, control your blood pressure (recommendations have tightened to define hypertension as any BP >130/80), and check your electrolyte balance. Be really careful with over-the-counter medications (cough meds, decongestants, cold meds, bronchodilators, etc.); the list is long. Also, check the labels of things in your daily life that you pay little attention to and cut out energy drinks and soft drinks that are full of cardiac stimulants that can trigger PVCs or give you more of them. One thing we can’t modify is aging or, as Neil Armstrong would put it, using up the finite heartbeats we’re given. Every heartbeat you’re “allotted” is a precious gift, so take advantage of every one of them, cherish every one, don’t waste a single one, but just be careful about wishing for more.

Kenneth Stahl, MD, FACS

Kenneth Stahl, MD, FACS is an expert in principles of aviation safety and has adapted those lessons to healthcare and industry for maximizing patient safety and minimizing human error. He also writes and teaches pilot and patient safety principles and error avoidance. He is triple board-certified in cardiac surgery, trauma surgery/surgical critical care and general surgery. Dr. Stahl holds an active ATP certification and a 25-year member of the AOPA with thousands of hours as pilot in command in multiple airframes. He serves on the AOPA Board of Aviation Medical Advisors and is a published author with numerous peer reviewed journal and medical textbook contributions. Dr. Stahl practices surgery and is active in writing and industry consulting. He can be reached at [email protected].

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