‘Where There’s Smoke …’

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See related article, pages 588–593. Premature ventricular complexes (PVCs) are easily recognized abnormalities on a 12-lead electrocardiogram or rhythm strip. During medical school and residency, it was a surprise and disappointment to learn that such an obvious abnormality was dismissed as a benign rhythm disturbance and was not indicative of serious disease. In this issue of Stroke, Agarwal and colleagues1 report that PVCs seen on a single baseline 2-minute rhythm strip were associated with an increased risk of incident stroke. These findings are reported in a large cohort (>14 000) of middle-aged (45 to 64 years) American men and women followed for 15 to 17 years in the Atherosclerosis Risk in Communities (ARIC) study. In the 6.1% with PVCs, the adjusted hazard ratio for stroke was 1.4 (95% CI, 1.08 to 1.80) and the adjusted hazard ratio for a combined end point of stroke and death was 1.62 (95% CI, 1.44 to 1.83). Increased stroke risk was observed irrespective of gender and race. There was a marked increase in stroke risk in those participants with ≥4 PVCs in a 2-minute recording. PVCs are suggested to be a “culprit arrhythmia”2 in the development of cardiomyopathy and are reported to predict a heightened risk of new-onset atrial fibrillation (AF)3 and cardiovascular death.4,5 An association of PVCs with stroke risk has been reported in an earlier smaller study cited by the ARIC investigators. In the large ARIC study, PVCs were associated with new-onset AF and death. Agarwal and colleagues1 identified apparent effect modification on stroke risk between established stroke risk factors and the …