Key Point

Among the many differentials for chronic cough, premature ventricular complexes should be included.

CHICAGO—Although chronic cough can result from asthma, nonasthmatic eosinophilic bronchitis, gastroesophageal reflux disease, upper airway cough syndrome, or a combination of these factors, the cause remains unknown in as many as a third of cases. In a study presented at the American College of Chest Physicians’ 2007 Annual International Scientific Assembly, premature ventricular complexes (PVCs) were implicated as a possible cause of chronic cough.

PVCs are common cardiac arrhythmias caused by ectopic impulses originating from an area distal to the His-Purkinje system. When PVCs appear in a person with an otherwise healthy heart, it usually has a benign prognosis, noted Elzbieta Grabczak of the Department of Internal Medicine, Pneumonology, and Allergology at Warsaw Medical University. While it is well known that cough can cause arrhythmias, whether arrhythmias cause cough has not been investigated, Dr. Grabczak said.

“In the American College of Chest Physicians’ guidelines, chronic cough is not included as even an uncommon symptom of ventricular arrhythmia,” she pointed out. “However, in the 1990s, a report was published of a patient who had had chronic cough for 15 years before it was discovered that this individual had a ventricular arrhythmia. After antiarrhythmic treatment, the cough disappeared.”

Dr. Grabczak’s interest in this phenomenon was piqued by the case of a woman who presented with chronic cough and cough syncope associated with PVCs. The association between the cough and PVCs became apparent after ECG monitoring, and the investigators were able to document the phenomenon with a portable multichannel recorder. Radiofrequency ablation (RFA) resulted in the complete elimination of both chronic cough and cough syncope.

“This patient was the incentive for us to determine how to diagnose and treat patients with cough caused by PVCs,” Dr. Grabczak said.

For the present study, Dr. Grabczak and colleagues prospectively evaluated the incidence and management of chronic cough in 120 consecutive patients referred for the management of symptomatic PVCs. Organic heart disease was excluded by medical history, ECG, and exercise testing. PVC-induced cough was recognized when cough episodes occurred just after spontaneous or induced PVCs, as observed on ECG. More detailed information was provided by polysomnographic equipment that allowed for simultaneous ECG and cough recording. Patients were assessed during both normal breathing and deep inspiration and expiration. To exclude other causes of cough, differential diagnostics were performed, including spirometry, methacholine challenge, sputum induction for cytological analyses, sinus CT, videolaryngoscopy, and 24-hour esophageal pH monitoring.

Ten patients were found to have a history of chronic cough, and in six, a relationship between cough and PVCs could be established. All patients with PVC-induced cough were women (average age, 45; average cough duration, 1.5 years). Antiarrhythmic medication resulted in a significant decrease in cough in five of six patients; however, four patients were referred for RFA because of drug intolerance or preference for curative treatment. PVC-induced cough was eliminated immediately following successful RFA of the arrhythmogenic focus.

Dr. Grabczak said, “PVCs can be a cause of cough and should be included in the differential diagnosis of cough. We need to characterize the PVC-induced cough phenotype and to elucidate the mechanism involved in this phenomenon. Antiarrhythmic therapy should be evaluated to determine if it is effective, but cooperation between pulmonologists and cardiologists is essential to reach these goals.”           

—Laurel McKee Ranger

Suggested Reading
Stec S, Dabrowska M, Zaborska B, et al. Premature ventricular complex-induced chronic cough and cough syncope. Eur Respir J. 2007;30(2):391-394.

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