When to Refer Patients with PACs on EKG
Most patients with premature atrial contractions (PACs) on EKG do not require referral to a cardiologist or electrophysiologist, as PACs are nearly universal and typically benign. 1
Initial Assessment and Management
First, identify and eliminate reversible causes before considering referral:
- Assess for excessive caffeine, alcohol, nicotine intake, recreational drugs, or hyperthyroidism 1
- Review medications that may provoke PACs 2
- Correct electrolyte abnormalities if present 2
- If PACs resolve with elimination of triggers and the patient is asymptomatic, no referral is needed 1
Clear Indications for Referral
Refer to a cardiac arrhythmia specialist in these specific situations:
High-Risk Features Requiring Prompt Referral
- Severe symptoms during palpitations, including syncope or dyspnea 1
- Pre-excitation (Wolff-Parkinson-White pattern) on baseline EKG with history of palpitations - these patients are at risk for sudden death and require immediate electrophysiological evaluation 1
- Irregular palpitations in a patient with baseline pre-excitation, suggesting atrial fibrillation episodes 1
- Wide complex tachycardia of unknown origin 1
Symptomatic PACs Despite Conservative Management
- Drug-refractory symptomatic PACs - patients who remain symptomatic despite beta-blocker therapy 1, 2
- Patients desiring to be free of drug therapy who have documented symptomatic PACs 1
- Frequent symptomatic PACs (>20,000 per 24 hours) with significantly impaired quality of life - catheter ablation has proven safe and effective in these patients 3
When Referral is NOT Indicated
Do not refer in these situations:
- Asymptomatic PACs on routine EKG - these are present in nearly all individuals on long-term monitoring 1, 2
- Benign extrasystoles that are manifest at rest and become less common with exercise 1
- PACs that resolve after eliminating precipitating factors 1
Additional Testing Before Referral Decision
Consider these investigations to guide your referral decision:
- Echocardiogram to exclude structural heart disease, particularly if PACs are sustained or frequent 1
- 24-hour Holter monitor for patients with frequent symptoms (several episodes per week) to quantify PAC burden 1
- Event or loop recorder for less frequent arrhythmias (more useful than 24-hour Holter for infrequent symptoms) 1
- Exercise stress testing if arrhythmia is clearly triggered by exertion 1
Important Clinical Context
While frequent PACs (>700 per 24 hours) are associated with future atrial fibrillation development 4, this association alone does not mandate referral in asymptomatic patients. However, be aware that frequent PACs on Holter monitoring are associated with increased risk of atrial fibrillation (HR 2.96), stroke (HR 2.54), and mortality (HR 2.14) 4, which should inform your monitoring strategy even if immediate referral is not indicated.
The key distinction is between asymptomatic PACs (manage conservatively) versus symptomatic, drug-refractory, or high-risk features (refer to specialist). 1