How to treat Premature Atrial Contractions (PACs)?

Treatment of Premature Atrial Contractions (PACs)

Beta-blockers are the first-line treatment option for symptomatic PACs to control symptoms and prevent progression to atrial fibrillation. 1

Initial Evaluation and Management

• Assess for potentially reversible causes of PACs before initiating specific treatments:

  • Electrolyte abnormalities (particularly potassium and magnesium deficiencies) 1
  • Hyperthyroidism 1
  • Stimulant use (caffeine, medications) 1
  • Sleep apnea (associated with increased PACs and risk of AF) 1, 2

• Address modifiable risk factors as part of first-line management:

  • Reduce alcohol and caffeine intake 1
  • Treat underlying conditions (hyperthyroidism, sleep apnea) 1
  • Correct electrolyte abnormalities 1

Pharmacological Management

First-Line Therapy

• Beta-blockers are recommended as initial pharmacological therapy for symptomatic PACs 1
  • Effective for symptom control
  • Help prevent progression to atrial fibrillation
  • Can reduce PAC burden by attenuating sympathovagal imbalance 2

Second-Line Therapy

• For patients with persistent symptoms despite beta-blockers:
  • Sotalol may be considered for both rate control and PAC suppression in patients with severe symptoms 1
  • Amiodarone can be considered in patients with structural heart disease and symptomatic PACs 1
  • Flecainide may be used for PAF (paroxysmal atrial fibrillation) patients with PACs at a starting dose of 50 mg every 12 hours, which can be increased in increments of 50 mg twice daily every four days until efficacy is achieved (maximum recommended dose: 300 mg/day) 3

Advanced Management Options

• Catheter ablation should be considered for patients with:
  • Symptomatic, frequent, and drug-refractory PACs 4
  • PACs triggering atrial fibrillation 4
  • Success rates for PAC ablation are high (82-100%) with low recurrence rates 4

Monitoring and Follow-Up

• Monitor patients with frequent PACs for development of atrial fibrillation, as they represent a high-risk group 1, 5
• Consider anticoagulation based on CHA₂DS₂-VASc score if atrial fibrillation develops 1
• Evaluate for adverse left atrial remodeling, as frequent PACs are associated with reduced left atrial contractile function and increased left atrial volume 6

Important Considerations and Caveats

• PACs with shorter coupling intervals (particularly <400 ms) have higher risk of triggering AF compared to those with longer coupling intervals 4
• Avoid class IC antiarrhythmics (flecainide, propafenone) in patients with structural heart disease due to increased risk of proarrhythmia 1
• Avoid digoxin in patients with pre-excited AF (e.g., WPW syndrome) as it may accelerate ventricular rate 1
• Consider that frequent PACs may be a marker of atrial cardiomyopathy and associated with increased risk of stroke and mortality even in the absence of documented AF 5, 7