From the Guidelines
Premature atrial complexes (PACs) typically do not require treatment if the patient is asymptomatic, as they are generally benign and common in healthy individuals. The management of PACs is primarily focused on alleviating symptoms and improving quality of life, rather than solely treating the arrhythmia itself. According to the 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1, the detection of premature complexes, particularly if frequent, is generally considered a risk factor for adverse cardiovascular outcomes. However, this guideline primarily discusses premature ventricular complexes (PVCs) rather than PACs, and the management strategies for PVCs may not directly apply to PACs.
Treatment Approach
When PACs cause significant symptoms such as palpitations, dizziness, or shortness of breath that affect quality of life, treatment may be necessary. The first approach involves lifestyle modifications including:
- Reducing caffeine, alcohol, and nicotine intake
- Managing stress
- Improving sleep quality If symptoms persist, medication options include:
- Beta-blockers (such as metoprolol 25-100 mg twice daily or atenolol 25-100 mg once daily)
- Calcium channel blockers (such as diltiazem 120-360 mg daily or verapamil 120-360 mg daily) These medications work by slowing conduction through the AV node and reducing heart rate, which can decrease the frequency of PACs.
Considerations for Treatment
The decision to treat PACs should be individualized based on symptom severity, frequency of PACs, underlying cardiac conditions, and the patient's overall health status. It's essential to weigh the potential benefits of treatment against the risks, especially considering that treatment of PVCs with antiarrhythmic medications has not been shown to reduce mortality and may even increase the risk of death in certain populations 1. Therefore, a cautious approach, focusing on symptom management and lifestyle modifications, is often the most appropriate strategy for managing PACs.
From the Research
Treatment of Premature Atrial Complexes
- Premature atrial complexes (PACs) are a common finding in patients with structural heart disease, as well as in healthy subjects 2.
- Medical treatment can lead to a significant reduction in PACs with clear symptom relief in a large proportion of patients, but is limited in cases of PACs that are refractory to antiarrhythmic drug (AAD) treatment 2.
- Ablation of PACs is a good alternative to medical therapy with a comparable safety profile and at least comparable efficacy 2.
- Beta blockers may help to reduce PAC symptoms and improve long-term outcomes, with a significant reduction in mortality rates 3.
Association with Adverse Outcomes
- Frequent PACs are associated with an increased risk of stroke and death 4.
- The meta-analysis demonstrated that frequent PACs were associated with an increased risk of stroke and death from all causes, cardiovascular diseases, and coronary artery disease 4.
- Premature complexes had low density and were associated with brain natriuretic peptide (BNP) levels > 20mg/dL, lower levels of HDL-cholesterol, left atrial enlargement, and ventricular hypertrophy 5.
Treatment Options
- Antiarrhythmic drugs (AADs) play an important role in the treatment of premature ventricular complex-induced cardiomyopathy (PVC-CM) 6.
- Beta-blockers and calcium channel blockers are particularly effective in the treatment of PVCs originating from right ventricular outflow tract 6.
- Class Ic AADs, such as flecainide and propafenone, are effective in PVC suppression, but their usage is not recommended in patients with significant coronary artery disease 6.
- AADs are indicated for polymorphic PVCs, epicardial PVCs, and when catheter ablation (CA) procedure is contraindicated, or not feasible or failed 6.