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Occupational Health
J Occup Health 2002; 44: 343–347
The Association between the Pattern of Premature Ventricular
Contractions and Heart Diseases: Assessment of Routine
Electrocardiography in Health Examinations
Kazuhito HATANAKA1, Akira FUJINAMI2, Yoshihiro NISHIMOTO2,
Nobuhiko ITO3 and Masahiko KOBAYASHI1
1
Department of Forensic Medicine, Graduate School of Medicine, University of Tokyo,
Central Health Institute of East Japan Railway Company and
3
Department of Cardiology, JR Tokyo General Hospital, Japan
2
Abstract: The Association between the Pattern of
Premature Ventricular Contractions and Heart
Diseases: Assessment of Routine
Electrocardiography in Health Examinations:
Kazuhito HATANAKA, et al. Department of Forensic
Medicine, Graduate School of Medicine, University
of Tokyo—Objective—Premature ventricular
contractions (PVCs) were observed among patients
with heart diseases. It has been suggested that the
sporadic left bundle branch block (LBBB) pattern of
PVCs observed in healthy subjects has no relevance
to heart diseases and the presence of this type of PVC
was not associated with a poor prognosis. The aim of
this study is to present and evaluate the relationship
between PVC patterns on routine electrocardiography
(ECG) and heart diseases. Methods: The subjects
examined were 201 employees from one company
(male 192, female 9) with PVCs (Lown grading
classification 0 or 1). The patterns of PVCs were
classified into the following four categories regarding
the bundle branch block pattern and electrical axis
deviation: 1) the LBBB pattern without axis deviation
(135 subjects), 2) the LBBB pattern with left axis
deviation (29 subjects), 3) the right bundle branch block
(RBBB) pattern without axis deviation (22 subjects) and
4) the RBBB pattern with left axis deviation (15
subjects). Results—The presence of subjective
symptoms was not significant in each category.
Prevalence of heart disease was 1) 14 (10.4%), 2) 10
(34.5%), 3) 9 (40.9%) and 4) 7 (46.7%). The subjects
with the LBBB pattern without axis deviation had a lower
incidence of having heart disease than subjects with
other PVC patterns (p<0.05). In addition, similar
Received Feb 8, 2002; Accepted June 13, 2002
Correspondence to: K. Hatanaka, Department of Forensic
Medicine, Graduate School of Medicine, University of Tokyo, 7–
3–1 Bunkyo-Ku, Hongo, Tokyo 113-0033, Japan
findings applied to the observations in asymptomatic
subjects. Conclusion—It is suggested that the
population without heart disease primarily has the PVCs
of the LBBB pattern without axis deviation and the
analysis of the PVC patterns (bundle branch block
pattern) and of electrical axis deviation in routine ECG
at a routine health examination is useful for diagnosing
heart disease.
(J Occup Health 2002; 44: 343–347)
Key words: Premature ventricular contractions, Heart
disease, Electrocardiography, Bundle branch block,
Electrical axis deviation
Arrhythmia is one of the markers of heart disease.
Premature ventricular contractions (PVCs) are the most
common type of arrhythmia and PVCs are suggested to be
associated with heart diseases, such as ischemic heart
disease, cardiomyopathy, obstructive pulmonary disease
and valvular disease1–3). In ischemic heart disease, frequent,
multiform or early-coupling (R-on-T phenomenon) PVCs
are regarded as warning arrhythmias4, 5). PVCs also occur
in relation to various stimuli such as electrolyte
imbalance, tension states and central and peripheral
autonomic stimulation 6). Therefore, when PVCs are
detected by electrocardiography (ECG), a close
examination is often required to investigate the presence
of underlying disease. PVCs are also provoked by
smoking as well as caffeine or alcohol intake3, 6, 7), so that
they are frequently observed in a healthy population.
Other studies have shown that PVCs in healthy subjects
are sporadic and show no connection with heart disease8–13).
In the PVCs of subjects without heart disease, the left
bundle branch block (LBBB) pattern varied from 60 to
96% and the right bundle branch block (RBBB) pattern
varied from 4 to 33%10–12). In the PVCs of subjects with
344
heart disease, the LBBB pattern varied from 18 to 22%
and the RBBB pattern varied from 73 to 83% 12). In
subjects without ischemic heart disease, the LBBB pattern
was 74%, the RBBB pattern was 17% and both pattern
were 9%13). In subjects with ischemic heart disease, the
LBBB pattern was 35%, the RBBB pattern was 46% and
both were 19% 13). In general, most PVC patterns in
healthy subjects show an LBBB pattern. In addition to
the PVC pattern, it is also useful to make other
observations regarding the presence or absence of heart
disease on routine ECG at a health examination. We
therefore studied the degree of electrical axis deviation
as a useful indicator.
In the present study we analyzed sporadic PVC patterns
(bundle branch block pattern) and electrical axis deviation
in 201 subjects in routine ECGs. We also examined the
association between PVC patterns, electrical axis
deviation and the presence of heart disease.
Subjects and Methods
The subjects of this study were 201 employees from
one company who had one or more PVCs on a routine
12-lead ECG obtained during a health examination. There
were 192 males and 9 females, with ages ranging from
19 to 56 yr (mean of 44.4 yr). All subjects underwent a
clinical examination for heart diseases in medical facilities
and their medical history was reviewed. Subjects with
atrial fibrillation (valvular heart disease, lone atrial
fibrillation, ischemic heart disease, cardiomyopathy),
conduction disturbance (atrioventricular block, left bundle
branch block, right bundle branch block, WolffParkinson-White syndrome), who were taking
antiarrhythmics drugs or who showed poorly recorded
ECG tracing were excluded from the study population.
Subjects corresponding to Lown’s grades14) 2–5 were also
excluded. The QRS complexes were diagnosed as PVCs
not by automatic data processing, but by physicians
according to the following criteria: (1) premature, (2) not
preceded by a premature P wave, (3) with a duration of
0.12 s or greater and (4) with a different morphology
from the dominant rhythm13). The RBBB pattern was
diagnosed when there was a QRS duration of 0.12 s or
greater with a QR, RSR’ or RR’ pattern in the V1 lead15).
The LBBB pattern was diagnosed when there was a QRS
duration of 0.12 s or greater and a predominantly negative
QRS complex with a terminal S wave in the V1 lead16).
The mean electrical axis deviation was measured in the
QRS complex, and the QRS frontal-plane vector, between
–30° and –90°, was defined as left axis deviation17, 18).
Subjects were placed into the following four categories,
based on their PVC patterns and electrical axis deviation:
(1) LBBB pattern without axis deviation, (2) LBBB
pattern with left axis deviation, (3) RBBB pattern without
axis deviation, (4) RBBB pattern with left axis deviation.
The presence or absence of heart disease was also
J Occup Health, Vol. 44, 2002
Table 1. Characterization of premature ventricular
contraction in 201 subjects
Pattern of PVCs
No.
% of group
LBBB without AD
LBBB with LAD
RBBB without AD
RBBB with LAD
135
29
22
15
67.2
14.4
10.9
7.5
Total
201
100
Abbreviations: PVCs=premature ventricular contractions;
LBBB=left bundle branch block; RBBB=right bundle
branch block; AD=axix deviation; LAD=left axis deviation.
investigated in each category and the symptoms
associated with PVCs were detected, such as palpitations,
discomfort in the chest or feeling that the heart stopped
during the long pause after PVCs6).
Statistical significance was established by chi-square
analysis with Bonferroni correction for multiple
comparisons. Statistical differences were judged
significant at p<0.05.
Results
Individual classifications are shown in Table 1. The
heart disease diagnoses were as follows: 20 had
hypertensive cardiovascular disease, 11 had ischemic
heart disease, 5 had cardiomyopathy and 4 had valvular
heart disease. In excluded subjects, one at Lown’s grade
3 had neither symptoms nor heart disease and another at
Lown’s grade 4A had symptoms and ischemic heart
disease.
135 subjects had the LBBB pattern without axis
deviation, 29 had the LBBB pattern with left axis
deviation, 22 had the RBBB pattern without axis deviation
and 15 had the RBBB pattern with left axis deviation.
Of the 201 subjects, 25 had symptoms associated with
PVCs and 176 were asymptomatic. Of the 25 subjects
with symptoms, 11 had heart disease and 29 did not. Of
the 176 asymptomatic subjects, 29 had heart disease and
147 did not (Table 2). The asymptomatic subjects had a
lower incidence of heart disease than the symptomatic
subjects (p<0.05).
Of the 135 subjects with the LBBB pattern without
axis deviation, 16 had symptoms related to PVCs and
119 had no symptoms. Of the 29 subjects with the LBBB
pattern with left axis deviation, 4 had symptoms and 25
had no symptoms. Of the 22 subjects with the RBBB
pattern without axis deviation, 3 were symptomatic and
19 were asymptomatic. Of the 15 subjects with the RBBB
pattern with left axis deviation, 2 were symptomatic and
13 were asymptomatic. There was no significant
difference between the categories regarding the presence
Kazuhito HATANAKA, et al.: Association between PVC Patterns and Heart Disease
345
Table 2. Association between symptoms and heart diseases
Subjects
Heart diseases
No heart diseases
Total
Symptomatic (%)
Asymptomatic (%)
11 (44.0)
14 (56.0)
25
29 (16.5)
147 (83.5)
176
Total
40
161
201
χ2=13.1 (p<0.05)
Table 3. Association between PVC patterns and symptoms
Pattern of PVCs
Subjects
Symptomatic
Asymptomatic
Total
LBBB without
AD (%)
LBBB with
LAD (%)
RBBB without
AD (%)
RBBB with
LAD (%)
Total
16 (11.9)
119 (88.1)
135
4 (13.8)
25 (86.2)
29
3 (13.6)
19 (86.4)
22
2 (13.3)
13 (86.7)
15
25
176
201
χ2=0.168 (N.S.)
Abbreviations: PVCs=premature ventricular contractions; LBBB=left bundle branch block; RBBB=right
bundle branch block; AD=axis deviation; LAD=left axis deviation.
Table 4. Association between PVC patterns and heart diseases
Pattern of PVCs
Subjects
Heart diseases
No heart diseases
Total
LBBB without
AD (%)
LBBB with
LAD (%)
RBBB without
AD (%)
RBBB with
LAD (%)
Total
14 (10.4)
121 (89.6)
135
10 (34.5)
19 (65.5)
29
9 (40.9)
13 (59.1)
22
7 (46.7)
8 (53.3)
15
40
161
201
χ2=23.4 (p<0.05)
Abbreviations: PVCs=premature ventricular contractions; LBBB=left bundle branch block; RBBB=right
bundle branch block; AD=axis deviation; LAD=left axis deviation.
or absence of symptoms (Table 3).
The relationships between the PVC patterns and the
presence of heart disease are shown in Table 4. Of the
135 subjects with the LBBB pattern without axis
deviation, 14 had heart disease and 121 did not. Of the
29 subjects with the LBBB pattern with left axis deviation,
10 had heart disease and 19 did not. Of the 22 subjects
with the RBBB pattern without axis deviation, 9 had heart
disease and 13 did not. Of the 15 subjects with the RBBB
pattern with left axis deviation, 7 had heart disease and 8
did not. Subjects with the LBBB pattern without axis
deviation had a lower incidence of having heart disease
than subjects with other PVC patterns (p<0.05).
The data from 176 asymptomatic subjects are shown
in Table 5. Of the 119 subjects with the LBBB pattern
without axis deviation, 8 had heart disease and 111 did
not. Of the 25 subjects with the LBBB pattern with left
axis deviation, 7 had heart disease and 18 did not. Of the
19 subjects with the RBBB pattern without axis deviation,
9 had heart disease and 10 did not. Of the 13 subjects
with the RBBB pattern with left axis deviation, 5 had
heart disease and 8 did not. Asymptomatic subjects with
the LBBB pattern without axis deviation had a lower
incidence of heart disease than subjects with other PVC
patterns (p<0.05).
Discussion
We investigated the association between PVC patterns
with electrical axis deviation and the presence of heart
disease on routine ECG at a health examination in one
company. The sporadic LBBB pattern of PVCs without
axis deviation showed a significantly low incidence of
346
J Occup Health, Vol. 44, 2002
Table 5. Association between PVC patterns and heart diseases (for asymptomatic subjects)
Pattern of PVCs
Subjects
Heart diseases
No heart diseases
Total
LBBB without
AD (%)
LBBB with
LAD (%)
RBBB without
AD (%)
RBBB with
LAD (%)
Total
8 (6.7)
111 (93.3)
119
7 (28.0)
18 (72.0)
25
9 (47.4)
10 (52.6)
19
5 (38.5)
8 (61.5)
13
29
147
176
χ2=27.8 (p<0.05)
Abbreviations: PVCs=premature ventricular contractions; LBBB=left bundle branch block; RBBB=right
bundle branch block; AD=axis deviation; LAD=left axis deviation.
heart disease.
The focus of PVC can be identified by QRS
morphology; that is, the QRS complexes with the LBBB
pattern characterize right ventricular ectopic contractions
and the RBBB pattern characterize left ventricular ectopic
contractions13, 19, 20). In addition, PVCs originating within
the anterior division of the left bundle branch or the
anterior left ventricular wall present the RBBB pattern
with left posterior hemiblock, and those originating within
the posterior division of the left bundle branch or the
posterior left ventricular wall present the RBBB pattern
with left anterior hemiblock17, 19, 20). Thus, the focus of
the ventricular extrasystoles contributes to the QRS
morphology and since the majority of the PVCs in normal
subjects have the LBBB pattern, the focus must be the
right ventricle7, 11, 12). It is also suggested that the origin
is near the interventricular septum21). It is possible that
the QRS morphology of the PVCs is altered by differences
in the focus, because, anatomically, there is the Purkinje
network of left and right bundle branches in the
interventricular septum10). It is reported that the QRS
morphology of PVCs varies according to the focus in the
conduction system10). Consequently, there is no definite
tendency regarding the QRS morphology pattern of PVC,
when its origin is located in or near the interventricular
septum. Therefore, it is proposed that in populations
without heart disease, if the LBBB pattern has left axis
deviation, the RBBB pattern either lacks axis deviation
or has left axis deviation, the focus is in or near the
interventricular septum.
We also recognized that subjects with the LBBB pattern
with left axis deviation had a higher incidence of heart
disease than those with the LBBB pattern without axis
deviation. In the RBBB pattern of PVCs there was no
significant difference between the pattern with no axis
deviation and the pattern with left axis deviation. The
reason for the predominance of the LBBB pattern with
left axis deviation in the presence of heart disease is
unclear. It is possible that left axis deviation in the PVCs
also reflects heart disease. Further study of these aspects
is required.
The reason why PVCs predominantly originate in the
right ventricle (LBBB pattern) in the absence of heart
disease is not clear. According to a survey of
asymptomatic, healthy subjects, the ratio of the LBBB
pattern to the RBBB pattern is 3 to 111). It is possible that
these LBBB pattern PVCs reflect abnormalities in the
right ventricle and these abnormalities cannot be detected
clinically or even with invasive examination
(catheterization)22) or these PVCs may be prodromus of
the development of heart disease23), so that all LBBB
patterns do not always relate to the absence of heart
disease.
It is well known that Brugada syndrome causes cardiac
arrest from ventricular fibrillation24). In patients with
Brugada syndrome, the right precordial lead (V1-V3)
patterns resemble those seen in RBBB with variable STsegment elevation and a coved or saddle-type appearance,
and left axis deviation is occasionally present25). Recently,
screening of some families with Brugada syndrome has
revealed a distinct mutation in the gene associated with
functional abnormalities of channel behavior24). In view
of this finding, it is possible that some pathophysiological
disorder could be disclosed by a new examination such
as molecular biological techniques, in subjects with PVCs
without heart disease.
Although in the present study subjects without heart
disease primarily had PVCs of the LBBB pattern without
axis deviation, heart disease was observed in some cases
with the LBBB pattern lacking axis deviation. In addition,
it is reported that the occurrence of PVCs in subjects
without clinical heart disease is associated with the longterm increase in risk of cardiovascular disease 26).
Therefore, for subjects with PVCs, a regular medical
follow-up should be encouraged, and a close examination
may be necessary in some cases with PVC of the LBBB
pattern without axis deviation.
In summary, the findings of the present study suggest
that an analysis of PVC patterns with electrical axis
deviation could be useful for the detection of heart disease
Kazuhito HATANAKA, et al.: Association between PVC Patterns and Heart Disease
on routine ECG during health examinations. The
presence of a sporadic LBBB pattern of PVC without
axis deviation should indicate the absence of heart disease,
and in subjects with other PVC patterns a close
examination is encouraged to detect the presence of
underlying heart disease.
Acknowledgments: We would like to thank Mr. Katsumi
Mori (Department of Health Promotion Sciences, Graduate
School of Health Sciences and Nursing, University of
Tokyo), for thoughtful advice on statistical analysis.
References
1) MN Kotler, B Tabatznik, MM Mower and S Tominaga:
Prognostic significance of ventricular ectopic beats
with respect to sudden death in the late postinfarction
period. Circulation 47, 959–966 (1973)
2) AJ Moss: Clinical significance of ventricular
arrhythmias in patients with and without coronary
artery disease. Prog Cardiovasc Dis 23, 33–52 (1980)
3) MJ Horan and HL Kennedy: Ventricular ectopy.
History, epidemiology, and clinical implications. JAMA
251, 380–386 (1984)
4) JT Jr Bigger, FJ Dresdale, RH Heissenbuttel, FM Weld
and AL Wit: Ventricular arrhythmias in ischemic heart
disease: mechanism, prevalence, significance, and
management. Prog Cardiovasc Dis 19, 255–300 (1977)
5) HL Kennedy, JE Pescarmona, RJ Bouchard and RJ
Goldberg: Coronary artery status of apparently healthy
subjects with frequent and complex ventricular ectopy.
Ann Intern Med 92, 179–185 (1980)
6) Olgin JE, Zipes DP. Specific arrhythmias: diagnosis
and treatment. In: E Braunwald, DP Zipes, P Libby,
eds. Heart Disease: A Textbook of Cardiovascular
Medicine, Sixth edition. Philadelphia: W.B. Saunders
Company, 2001: 855–857.
7) HL Kennedy and SJ Underhill: Frequent or complex
ventricular ectopy in apparently healthy subjects. Am
J Cardiol 38, 141–148 (1976)
8) JN Ruskin: Ventricular extracystoles in healthy
subjects. N Eng J Med 312, 238–239 (1985)
9) HL Kennedy, JA Whitlock, MK Sprague, LJ Kennedy,
TA Buckingham and RJ Goldberg: Long-term followup of asymptomatic healthy subjects with frequent and
complex ventricular ectopy. N Eng J Med 312: 193–
197 (1985)
10) MB Rosenbaum: Classification of ventricular
extrasystoles according to form. J Electrocardiol 2,
289–297 (1969)
11) R G H i s s , K H Av e r i l l a n d L E L a m b :
Electrocardiographic findings in 67,375 asymptomatic
subjects. III. Ventricular rhythms. Am J Cardiol 6, 96–
347
107 (1960)
12) GW Manning, SP Ahuja and MR Gutierrez:
Electrocardiographic differentiation between
ventricular ectopic beats from subjects with normal and
diseased hearts. Acta Cardiol 23, 462–470 (1968)
13) S Lewis, C Kanakis, KM Rosen and P Denes:
Significance of site of origin of premature ventricular
contractions. Am Heart J 97, 159–164 (1979)
14) B Lown and M Wolf: Approaches to sudden death from
coronary heart disease. Circulation 44, 130–142 (1971)
15) EJ Swanick, F Jr LaCamera and HJ Marriott:
Morphologic features of right ventricular ectopic beats.
Am J Cardiol 30, 888–891 (1972)
16) S Talbot and LS Dreifus: Characteristics of ventricular
extrasystoles and their prognostic importance: a
reappraisal of their method of classification. Chest 67,
665–674 (1975)
17) MB Rosenbaum: The hemiblocks: diagnostic criteria
and clinical significance. Mod Concepts Cardiovasc
Dis 39, 141–146 (1970)
18) FD Fisher and HA Tyroler: Relationship between
ventricular premature contractions on routine
electrocardiography and subsequent sudden death from
coronary heart disease. Circulation 47, 712–719 (1973)
19) MB Rosenbaum: Types of right bundle branch block
and their clinical significance. J Electrocardiol 1, 221–
232 (1968)
20) MB Rosenbaum: Types of left bundle branch block
and their clinical significance. J Electrocardiol 2, 197–
206 (1969)
21) PR Sharma and EK Chung: Clinical implication of
surface morphology of ventricular premature
contractions. J Electrocardiol 13, 331–336 (1980)
22) RJ Pietras, R Mautner, P Denes, D Wu, R Dhingra, W
Towne and KM Rosen: Chronic recurrent right and left
ventricular tachycardia: a comparison of clinical,
hemodynamic and angiographic findings. Am J Cardiol
40, 32–37 (1977)
23) SR Spielman, EL Michelson, LN Horowitz, JF Spear
and EN Moore: The limitations of epicardial mapping
as a guide to the surgical therapy of ventricular
tachycardia. Circulation 57, 666–670 (1978)
24) AA Grace: Brugada syndrome. Lancet 354, 445–446
(1999)
25) J Brugada, R Brugada and P Brugada: Right bundlebranch block and ST segment elevation in leads V1
through V3: a marker for sudden death in patients
without demonstrable structural heart disease.
Circulation 97, 457–460 (1998)
26) M Bikkina, MG Larson and D Levy: Prognostic
implications of asymptomatic ventricular arrhythmias:
the Framingham Heart Study. Ann Intern Med 117,
990–996 (1992)