From the Research
The management approach for a patient with sinus rhythm, premature atrial contractions (PACs), and left axis deviation on an EKG should prioritize evaluation for underlying structural heart disease and assessment of symptoms. For asymptomatic patients with isolated PACs, no specific treatment is typically necessary as these are often benign findings, as noted in a case report where atrial premature contractions (APCs) were found to influence heart conduction system and induce other arrhythmia 1. If the patient is symptomatic with palpitations or anxiety, first-line treatment includes lifestyle modifications such as reducing caffeine, alcohol, and stress. For persistent symptoms, beta-blockers like metoprolol (25-100 mg twice daily) or calcium channel blockers such as diltiazem (120-360 mg daily in divided doses) may be prescribed. The left axis deviation should prompt evaluation for underlying structural heart disease, including echocardiography to assess for left ventricular hypertrophy, conduction abnormalities, or other cardiac pathology, as left axis deviation is one of the most commonly encountered ECG abnormalities and its presence should alert medical directors and underwriters to the possibility of underlying structural heart disease 2. Additional workup may include 24-hour Holter monitoring to quantify PAC burden and identify any other arrhythmias. It's also important to consider the possibility of a Mahaim fiber, especially if there's an "rS" pattern in lead III during sinus rhythm, which can be associated with left axis deviation during tachycardia with anterograde conduction over the Mahaim fiber 3. Key considerations in management include:
- Evaluation for underlying structural heart disease
- Assessment of symptoms and PAC burden
- Lifestyle modifications for symptomatic patients
- Potential use of beta-blockers or calcium channel blockers for persistent symptoms
- Further workup with echocardiography and 24-hour Holter monitoring as needed.