Do PVCs count in HR?

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.

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 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.

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.