Q. What can be done for irregular heartbeat with chest and shoulder pain?

Answered by
Dr. Carlos L. Alviar
and medically reviewed by iCliniq medical review team.
This is a premium question & answer published on Feb 17, 2019

Hello doctor,

I am an 18-year-old female, no current medications, no known conditions, family history of many different heart problems on both maternal and paternal sides, seen by a cardiologist for bigeminy and irregular heartbeat over the summer, palpations still happen pretty often, chest and shoulder pain both on the left side still happening occasionally. Told by my cardiologist that I have nothing to worry about at all, have not talked to her since then. Yesterday, I got my paperwork and my test results from wearing the 24 hour Holter monitor and I am extremely worried.

Dr. Carlos L. Alviar

Cardiology Critical Care Physician


Welcome to icliniq.com.

What you have is called premature ventricular contractions (AKA PVCs), which are extra beats coming from the bottom chamber of the heart and in some occasions they present in every other beat (what is called ventricular bigeminy) (attachment removed to protect patient identity). These beats can be tolerated as normal in many individuals, However, there are two things that are the most important factors to consider:

1. What is the burden (amount or percentage of PVCs in 24 hours in your heart? While some people say that up to 6 PVCs per hour is normal, the number that cardiologist gets worried is more than 10,000 or more than 20,000 in 24 hours. The main reason we get worried with this number is because this is the limit when PVCs can be associated with impairment of the squeezing function of the heart.

2. What is the heart function, in particular, what is the ejection fraction (squeezing function) which in other words is the ability to pump the blood? If the ejection fraction is low, we have to explore the amount of PVCs (particularly if more than 10,000 in 24 hours) as a potential cause of this low pumping function. This is something that can be done with an ultrasound of the heart. If we do see that the pumping function is low and there are more than 10000 PVCs in 24 hours, we need to consider treating this with medications, a catheter-based procedure or both.

Finally, it is important to determine if you have a lot of symptoms, in particular, palpitations, dizziness, fainting or chest pain, in a regular basis and if these symptoms are interfering with your life.

The Probable causes:


Investigations to be done:

Echocardiogram, treadmill stress test, to assess if the PVCs get suppressed or not during exercise.

Differential diagnosis:

PACs with aberrancy.

Probable diagnosis:


Treatment plan:

Echocardiogram, treadmill stress test. Low dose beta blocker (Metoprolol or Propanolol) can be used once we have a confirmatory burden in the Holter.

Regarding follow up:

Please verify if the Holter report has a percentage of PVCs in 24 hours. I did not see it in the attached picture.

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