Do PVCs count in HR?

vamedic4, EMT-P · Jan 22, 2007

Megsd said:
My instructors, my classmates, and my paramedic boyfriend all have different opinions on this matter and I can't get a straight answer out of anybody.
When looking at an EKG strip and calculating the heart rate by counting R waves, do you include PVCs? I have been told that you do not count them because they do not contribute to cardiac output, I have been told that you do count them if they perfuse (which there's no way to verify by looking at a strip).
I have been told that you need to "treat the underlying rhythm." But say you have a strip that, including PVCs, has a rate of 70, but without them, has a rate of 50. Does the patient have a bradycardia they should be treated for with atropine (assuming they are symptomatic) or is their rate really 70 and they don't need treatment?
So do you count them or not?

Some PVC's do actually conduct a beat, so there is a "pulse" that goes along with them. The key here is to palpate a pulse when assessing HR, don't just look at the monitor. If you feel a pulse but see a PVC, then it counts toward the HR. If not, then no.

And again, with your rate question...it is patient dependent. Theoretically you should treat a pt. with an underlying bradycardia and PVCs with Atropine first (rate first, then rhythm)...as you said, assuming they're symptomatic.

Hope that helps.

vamedic4

headaches suck

Daytonite, BSN, RN · Jan 22, 2007

If you are doing a physical assessment of the patient, you won't detect a PVC at a peripheral pulse point. So, no, you wouldn't count a PVC in the HR in that case.

If you are diagnosing a rhythm strip you would determine the patient's heart rate from a series of as normally conducted QRS complexes as you can find. A PVC has too wide a QRS complex and shouldn't be used in determining the patient's underlying heart rate on a rhythm strip either. So, no, you wouldn't count a PVC in the HR in that case either.

allnurses Guide · Jan 22, 2007

Megsd said:
My instructors, my classmates, and my paramedic boyfriend all have different opinions on this matter and I can't get a straight answer out of anybody.
When looking at an EKG strip and calculating the heart rate by counting R waves, do you include PVCs? I have been told that you do not count them because they do not contribute to cardiac output, I have been told that you do count them if they perfuse (which there's no way to verify by looking at a strip).
I have been told that you need to "treat the underlying rhythm." But say you have a strip that, including PVCs, has a rate of 70, but without them, has a rate of 50. Does the patient have a bradycardia they should be treated for with atropine (assuming they are symptomatic) or is their rate really 70 and they don't need treatment?
So do you count them or not?

Assuming that this pt is having 20 PVCs in one minute! I don't think that atropine would be the drug you would want to give...lidocaine, amidorone, or some other antiarrythmic would be a better choice. The most important thing to identify is what you already mentioned 70BPM with 20 PVCs (also need to identify if they are unifocal or multifocal PVCs) and if the pt is symptomatic.

Interesting question I don't think I have ever heard someone ask that question before.

Megsd, BSN, RN · Jan 22, 2007

wtbcrna said:
Assuming that this pt is having 20 PVCs in one minute! I don't think that atropine would be the drug you would want to give...lidocaine, amidorone, or some other antiarrythmic would be a better choice. The most important thing to identify is what you already mentioned 70BPM with 20 PVCs (also need to identify if they are unifocal or multifocal PVCs) and if the pt is symptomatic.
Interesting question I don't think I have ever heard someone ask that question before.

I wouldn't necessarily assume they are having 20 PVCs in a minute unless the strip appears that they are bigeminal, trigeminal, etc. Some people just have PVCs at random, and it could just be my luck that I caught 2 on the same strip.

Assuming they were having 20 PVCs a minute, yeah, my priority would be to determine the underlying cause of the PVCs (electrolyte imbalances, etc.) and treat that, maybe use some lidocaine, etc. I was more referring to just the odd random PVC, not a regular pattern of them.

The reason I am so curious is partly because I am responsible for interpreting strips on exams, and because all of the clinical units I am on this quarter (advanced care and CICU), every patient is on a heart monitor and one of my morning duties is to pull a strip and analyze it for the chart. I guess part of this is a moot point because if I am looking at a strip that comes off a heart monitor, the monitor will put the HR there for me. Which begs the question: do heart monitors count PVCs in the rate? Hmm... I'll have to start looking.

Daytonite, BSN, RN · Jan 22, 2007

Megsd said:
The reason I am so curious is partly because I am responsible for interpreting strips on exams, and because all of the clinical units I am on this quarter (advanced care and CICU), every patient is on a heart monitor and one of my morning duties is to pull a strip and analyze it for the chart. I guess part of this is a moot point because if I am looking at a strip that comes off a heart monitor, the monitor will put the HR there for me. Which begs the question: do heart monitors count PVCs in the rate? Hmm... I'll have to start looking.

I believe that heart monitors count the heart rate according to the P waves, but I could be wrong. On patients with pacemakers, they count by the pacer spikes emitted, so maybe it's the spike of the QRS complex that does it. You can probably find the answer to this question easily by going onto one of the websites of the monitor manufactures and looking at the specs for the equipment or an online operating manual. I'll bet you that at least one of the nurses over on the critical care forums will be able to answer this question for you!

I'm pretty sure that the monitors DO NOT count the PVCs in their rate. That's why all the bells and whistles go off when they have runs of them. I believe a monitor determines heart rate very much like the pulse ox does. It seeks certain waves and then does a mathematical calculation to average what it finds. If you have a patient with a very irregular heart rate, the monitor is still going to give you a heart rate, but it will be an averaged rate. If you sit and watch the monitor of a patient with an irregular rate, the monitor changes the heart rate constantly. It's fascinating to watch.

When you are diagnosing a rhythm strip you base the heart rate on the complete P-QRS complexes you've got on the strip, not on any of the PVCs. The heart rate is determined by measuring the distance between two QRS waves--the R-R or P-P intervals. PVCs don't have P waves. They are ectopic, initiate in the ventricles and only have QRS waves. Normally, you can't even find a nice spike on their QRS complex to base any kind of rate measurement on since they are so wide. If I were sitting at the monitors, I would watch a patient's monitor for a couple of minutes to see just how many PVCs they were throwing a minute and note this in my charting.

pipersjo, ADN, BSN, MSN · Jan 22, 2007

Since I am a Cardiac Monitor Tech, I thought that I had to put in my :twocents: . Not that I am going to be right or anything (I am rarely right, LOL!), but when I am interpreting my strips, I do not count the PVC's in the rate. As someone else pointed out, you can't really tell from a 6 second strip whether or not the PVC's are perfusing. Unless it is perfusing, it should not be included in the hr. Like I said, that is just my :twocents: and, lord knows, I am frequently wrong!

cardiacRN2006, ADN, RN · Jan 22, 2007

Our monitors do include PVCs into the HR. I also include them in the rate when interpreting the strip. I mean, the heart is beating with a PVC, so by definition it is part of the HR. If they don't perfuse, then it's not part of the pulse. But if I have a pt with a HR of 70 with frequent PVCs, I don't subtract how many PVCs from the monitor rate and tell the Dr that I have a HR of 50, because it's not true; I would say I have a HR of 70 with frequent PVCs, and the pt is symptomatic (or not).

regglynn · Jan 22, 2007

I just finished my critical care component and we interpreted EKGs. My instructors told us NOT to include them with the rate.

allnurses Guide · Jan 22, 2007

cardiacRN2006 said:
Our monitors do include PVCs into the HR. I also include them in the rate when interpreting the strip. I mean, the heart is beating with a PVC, so by definition it is part of the HR. If they don't perfuse, then it's not part of the pulse. But if I have a pt with a HR of 70 with frequent PVCs, I don't subtract how many PVCs from the monitor rate and tell the Dr that I have a HR of 50, because it's not true; I would say I have a HR of 70 with frequent PVCs, and the pt is symptomatic (or not).

I totally agree you with CardiacRN2006. I have called the physician many times for frequent PVCs/ short runs of Vtach etc. and I always do it that way.

kwtrn · May 19, 2010

No, you do NOT count the PVCs as part of the baseline HR. To answer your original question, the interpretation would be sinus brady with PVCs -- if the HR was 50 and had 2 PVCs noted. :)