Would you initiate anti-arrhythmic drug therapy in patients who are asymptomatic and have normal LV function but with a PVC burden > 20 percent?

I overall agree with Dr. @Dr. First Last's approach. There are important considerations with high-burden PVCs beyond LVEF. The morphology can be helpful with regard is this consistent or atypical appearance of idiopathic PVCs. I will typically do an assessment for underlying structural heart disease...

In my younger days I've managed high-burden PVCs with minimal to no symptoms with a spectrum of strategies, including ablation (I've had a case of LVS PVC/VT ablation with late resolution akin to Candemir et al., PMID 30822513), BB, flecainide (case of resolved PVCs after medication holiday), and ob...

I think these patients are better suited for ablation, to prevent VPC-induced LV dysfunction, which may occur at this level of burden. If they do not consider an invasive procedure, I would not treat, since they are asymptomatic and the risk of AAD is not worth the benefits. I would monitor their LV...