Atrial and Ventricular extrasystoles linked to Stroke or other cardiovascular problems.

[Chinkoflight]

I had a severe cryptogenic stroke 5 weeks ago. 5 years ago I was checked for bradycardia and irregular pulse. Outcome of holter etc was bradycardia with ectopic beats but no action. Full investigations of my MCA infarct has turned up nothing except repeat of the finding of atrial and ventricular extrasystoles. I have read a 2017 paper metadata study that found a clear relationship between these and stroke. Arguably I have just been added to that data. Is anybody in the same position and or aware of any centre researching this link?

[Pudin]

Think the jury is still out on this link. From what I could find the research seems to indicate that there needs to be a high burden of ectopics ( Pac's or Pvc's) and sustained bradycardia. One would hope if they had found this on Holter monitor some sort of treatment would have been offered?My understanding is that more or less everyone has a certain number of ectopics, so if they caused CVA's you would expect more to occur ?

What have your Doctor's said about this possible link?

Hope you are recovering well 🙂

[Chinkoflight in reply to Pudin]

Thank you for taking the time to reply. Yes you are right to point out that this phenomena is not uncommon so it's a wheat from the chaff exercise to understand the significance in those outcomes with a stroke. A metadata study that found the link called for research but I think in the scheme of things the QUALY's added for the general population is low and therefore it won't attract funding.

[Hidden]

Sorry to hear about your recent stroke. Generally speaking, and purely from my own reading and understanding as a layperson, neither PVCs nor PACs seem to be considered of interest for research: recent studies indicate that almost everyone has them on a daily basis, including those that are fit and well with no cardiac or circulatory pathology, and for the vast majority they’re infrequent and are deemed to be entirely benign. When things have been determined to occur in the majority but be mostly benign, unless that changes for some reason, they tend to get disregarded in favour of studying other issues with a greater negative impact. In the case of ectopics, beyond being tied to the autonomic nervous system (arising out of both the sympathetic and parasympathetic), that means the purpose, origin, and mechanism all currently remain unknown. The only thing they’re really done is research enough to establish when they should be considered a problem in their own right (which is a burden threshold of 10% a day or more, or runs of three or more ventricular without a normal beat in between), and that’s about it. We do know that extrasystoles can quite often increase after heart attack, though, and are also the primary trigger for episodes of both atrial fibrillation and supraventricular tachycardia in those with those particular arrhythmias, and my understanding is that those with inappropriate sinus tachycardia can also quite often have a higher number of ectopics. All of which would make clear sense when you consider the thinking that ectopics most likely get triggered from within the sinoatrial (SA) node, which is responsible for electrical signals governing heart rate and some elements of rhythm.

[Chinkoflight in reply to Hidden]

Thanks for the reply. I guess it's how hard one looks, but even the knowing may not bring about a treatment option. Hence querying whether any research was taking place. I am lucky that I had a severe stroke, but have made a rapid full recovery. I'm sure it's the same for everyone whatever the outcome, in the anxiety not knowing when the next stroke might occur, but for me I'm not really able to effect any changes within my control to reduce the risk of another stroke, eg exercise more, stop smoking etc. You end up looking around for stuff! Thanks again.

[Hidden in reply to Chinkoflight]

My daughter and I have a range of complex and in some cases quite unusual medical issues between us: I completely understand the need for answers, particularly where there’s a possibility of a repeat, and the frustration and fear when there are few (or none) to be found. There is a perception that medically we’re quite advanced, but in discussion with a number of exceptional medics over the years, particularly in paediatrics where they tend to be a bit more humble and open to admitting they’re fallible, I’ve come to the conclusion that our understanding in many areas is still little better than infantile. We’re small children learning the alphabet but getting some of the letters round the wrong way. Don’t know is still a commonly encountered answer, and in many areas, but certainly in terms of genetic understanding, we’ve barely even begun to scratch the surface.

Generally speaking, stroke is associated with atrial fibrillation as an arrhythmia, which is a high heart rate rather than a low one, but is triggered by ectopics. It’s always possible that you were having PACs and PVCs at the same frequency as you are now for many years prior to the holter 5 years ago. It’s also possible that they’re nothing to do with your stroke at all, but the converse could also be true: there’s just no way to know, unfortunately. I’ve done some reading since replying to you earlier, and the studies do suggest that there’s a correlation between those that have had stroke and ectopics, as well as the risk of recurrence, but it was also found that was only the case in those with no other risk factors. Anyone that had other predisposing factors in addition to regular ectopics had no higher incidence or risk of stroke. In a longitudinal study looking specifically at PACs and stroke risk (you may have already seen it, link below) they concluded that excessive PACs correlated to increased stroke and TIA risk, but the key word is excessive: the definition for excessive supraventricular ectopics (another term for atrial extrasystoles or PACs) is more than 30 a minute, which would be way above the threshold at which ectopics are considered a problem in their own right for most people in any event. As I said in my original reply, a burden of 10% or more is required to meet that threshold: using an average resting heart rate of 70bpm over 24 hours as an example, a 10% burden would mean having more than 10,000 PACs a day. If excessive supraventricular ectopics is defined as 30 PACs a minute or more, that equates to someone having a minimum of 43,000 in a day and a burden closer to 40%. Having looked at quite a few papers this afternoon, my understanding is that, as a result of all this, it’s difficult to draw a definitive conclusion about the role or predictive factor extrasystoles play, particularly if we’re now saying that everyone has them on a daily basis and people can have them very regularly without issue.

I know none of the above helps you. I hope you manage to better accept the ‘don’t know’ in time, but absolutely empathise with how you’re feeling. Sometimes all any of us can do is educate ourselves, follow whatever appropriate advice and treatment we’ve been given, and hope.

academic.oup.com/eurheartj/...

[Chinkoflight in reply to Hidden]

Thanks again. You have picked up on the correlation with no other risk factors which was the basis of my reading but probably not explained well enough on my part. Sometimes the breakthroughs come from studying the exceptions in all areas of research because you know you will find something new. I was hoping someone might have picked up on this given it was a recommendation from the original study. But there is so much unknown as the point is well made.

[Pudin in reply to Hidden]

Hi Charlie G my understanding is that ectopic beats are not triggered from the SA node hence 'ectopic' this link is one I found that seemed to explain it far better than I can-webmd.com/heart-disease/ect....

[Hidden in reply to Pudin]

Apologies, Pudin, you’re correct. The ectopic is triggered externally to the SN, but for those with the three arrhythmias I mentioned - SVT (which is the condition I have), AF, and potentially IST - the resultant arrhythmia arises from the sinus node in direct response to the ectopics. Not the ectopics themselves. My bad! 🙈

[Pudin]

Glad to hear you have covered well, completely understand the anxiety bit, it's so hard when there is no clear evidence of a cause and therefore a way to prevent it happening again. Must admit despite how far medicine has come in the last few decades there is still so much that is not clear or really understood.