How to manage a patient with a high burden of premature atrial contractions (PACs) and premature ventricular contractions (PVCs), experiencing occasional consecutive atrial ectopics and brief bursts of atrial tachycardia with normal heart rate (HR) but hypotension?

From the FDA Drug Label

For patients with PSVT and patients with PAF the recommended starting dose is 50 mg every 12 hours. Flecainide doses may be increased in increments of 50 mg bid every four days until efficacy is achieved Flecainide should be used cautiously in patients with a history of CHF or myocardial dysfunction

The patient has a high burden of premature atrial contractions (PACs) and premature ventricular contractions (PVCs), with occasional consecutive atrial ectopics and brief bursts of atrial tachycardia, but with a normal heart rate (HR) and hypotension (bP 98/60).

• The flecainide dose for PSVT and PAF is 50 mg every 12 hours, which may be increased every four days until efficacy is achieved.
• However, given the patient's hypotension, caution should be exercised when using flecainide, as it may worsen the condition.
• Additionally, flecainide should be used cautiously in patients with a history of CHF or myocardial dysfunction.
• There is no direct information in the provided drug labels that specifically addresses the management of a patient with a high burden of PACs and PVCs, with occasional consecutive atrial ectopics and brief bursts of atrial tachycardia, and hypotension.
• Therefore, a conservative approach would be to consider alternative treatment options or to consult with a cardiologist for further guidance 1, 1.

From the Research

Management of a patient with a high burden of premature atrial contractions (PACs) and premature ventricular contractions (PVCs) with occasional consecutive atrial ectopics, brief atrial tachycardia bursts, and hypotension should prioritize catheter ablation as a primary therapy, especially in patients with a high burden of PVCs, as suggested by the most recent study 2.

Initial Evaluation

Initial evaluation should include:

• 12-lead ECG
• 24-hour Holter monitoring
• Echocardiogram
• Laboratory tests to assess for structural heart disease, electrolyte abnormalities, and thyroid dysfunction

Treatment Approach

For symptomatic patients, consider the following treatment options:

• Beta-blockers like metoprolol (25-100 mg twice daily) or calcium channel blockers such as diltiazem (120-360 mg daily in divided doses) as first-line treatments
• Antiarrhythmic medications like flecainide (50-200 mg twice daily) or propafenone (150-300 mg three times daily) for patients without structural heart disease
• Amiodarone (200 mg daily after loading) for those with structural heart disease
• Catheter ablation for patients with refractory symptoms or those who cannot tolerate medications, as it has been shown to be effective and safe in the long term 3

Lifestyle Modifications

Lifestyle modifications such as:

• Reducing caffeine, alcohol, and stress
• Managing sleep apnea if present can help reduce ectopic burden

Regular Follow-up

Regular follow-up with cardiac monitoring is essential to assess treatment efficacy and adjust therapy as needed, considering the potential risks of atrial cardiomyopathy, incident atrial fibrillation, and stroke associated with frequent premature atrial contractions 4

Considerations

Considerations should be given to the therapeutic inefficacy and proarrhythmic nature of metoprolol succinate and carvedilol therapy in patients with idiopathic, frequent, monomorphic premature ventricular contractions, as reported in a recent study 5