What to do with an asymptomatic patient with sinus rhythm, premature atrial complexes (PACs), left axis deviation, and a borderline electrocardiogram (ECG) prior to discharge?

Management of Asymptomatic Patient with Sinus Rhythm, PACs, Left Axis Deviation, and Borderline ECG Prior to Discharge

For an asymptomatic patient with sinus rhythm, premature atrial complexes (PACs), left axis deviation, and a borderline ECG who is being discharged tomorrow, no specific intervention or additional testing is required before discharge.

Understanding the ECG Findings

The ECG findings in this patient include:

1. Sinus rhythm with PACs: Premature atrial complexes are common and generally benign in asymptomatic individuals
2. Left axis deviation: Considered a borderline finding according to international guidelines 1
3. Borderline ECG: This term typically refers to findings that are not clearly normal but also not definitively pathological

Clinical Significance of These Findings

Premature Atrial Complexes (PACs)

• PACs are common findings on ECG monitoring at all ages, with increasing frequency in older individuals 2
• In patients without heart disease, isolated PACs are generally considered benign 2
• While high PAC burden may be associated with development of atrial fibrillation in some patients, recent research shows that PACs alone are not associated with higher risk of stroke/TIA or death in patients with mild to moderate stroke 3

Left Axis Deviation

• Left axis deviation is specifically classified as a "borderline ECG finding" according to international guidelines 1
• When present in isolation, left axis deviation likely does not represent pathologic cardiovascular disease 1

Management Approach

Pre-discharge Assessment

• Since the patient is asymptomatic, no specific intervention is required prior to discharge
• The presence of isolated PACs and left axis deviation in an asymptomatic patient does not warrant delaying discharge or initiating treatment

Follow-up Recommendations

• Schedule a routine follow-up appointment within 10 days of discharge, consistent with recommended care for cardiac patients 1
• During follow-up, a repeat ECG may be considered to monitor for any changes

Patient Education

• Educate the patient about symptoms that would warrant medical attention (palpitations, dizziness, syncope)
• Explain that these ECG findings are common and generally benign in asymptomatic individuals

When Further Evaluation Would Be Warranted

Additional evaluation would be indicated if:

1. The patient develops cardiac symptoms (palpitations, dizziness, syncope)
2. Multiple borderline findings are present (according to guidelines, two or more borderline findings may warrant additional investigation) 1
3. There is a family history of sudden cardiac death or inherited cardiac conditions
4. The patient has high-risk occupations (e.g., pilots, public transport drivers) 1

Conclusion

In an asymptomatic patient with sinus rhythm, PACs, left axis deviation, and borderline ECG findings who is ready for discharge, no additional testing or treatment is necessary before discharge. Regular follow-up is appropriate to monitor for any changes in clinical status or ECG findings.