Can physician assistants (PAs) perform cardiac procedures, including management of atrial fibrillation?

Physician Assistants in Cardiac Procedures

Yes, physician assistants can and do perform cardiac procedures, with their scope defined by the 2020 American College of Cardiology competency guidelines, which specify that cardiovascular PAs are trained to participate in a wide range of cardiac procedures including cardioversion, device implantation, and electrophysiology procedures, though the extent varies based on practice focus and supervision requirements. 1

Scope of Cardiac Procedures for PAs

Arrhythmia Management and Cardioversion

• All cardiovascular PAs should have skills to evaluate and manage atrial arrhythmias, including rate control, rhythm control, and anticoagulation for atrial fibrillation. 1
• PAs are trained to participate in advanced cardiac life support, emergent defibrillation, transcutaneous pacing, and cardioversion. 1
• Skills to participate in elective cardioversion and manage associated risks and complications are core competencies. 1
• PAs can risk stratify patients with atrial fibrillation for embolic stroke and bleeding risk on anticoagulation. 1

Device-Related Procedures

• Selected cardiovascular PAs with specialized training can participate in the insertion of permanent pacemakers, internal cardiac defibrillators, or cardiac resynchronization devices. 1
• PAs can participate in the insertion of implantable loop recorders. 1
• Skills to interrogate, troubleshoot, program, and monitor performance of implanted cardiac devices are expected competencies. 1
• PAs provide perioperative care to patients receiving cardiac implantable electronic devices. 1

Invasive Electrophysiology

• Selected cardiovascular PAs can participate in invasive electrophysiology procedures, including catheter ablation. 1
• PAs manage patients following catheter ablation of atrial fibrillation, atrial flutter, supraventricular tachycardias, and ventricular arrhythmias. 1

Diagnostic Procedures

• Historical evidence demonstrates that PAs can perform coronary arteriography with complication rates comparable to cardiology fellows (1.3% minor complications in both groups, with no deaths, myocardial infarctions, or strokes in the PA group). 2
• Procedure and fluoroscopy times for PAs performing coronary arteriography were statistically equivalent to fellows. 2

Important Caveats and Supervision Requirements

Participation vs. Independent Performance

• The ACC guidelines consistently use the term "participate in" rather than "independently perform" for most invasive procedures, indicating that PAs work under physician supervision. 1
• The distinction between "selected" cardiovascular PAs (those with specialized training) and "all" cardiovascular PAs is critical—invasive procedures are typically limited to those with specific practice focus and additional training. 1

Recent UK Concerns

• A 2025 UK survey revealed significant concerns about PA scope of practice in cardiology, with 12.6% of respondents reporting PAs performing actions outside their scope, including prescribing (2.6%) and ordering ionizing radiation (5.2%). 3
• The survey documented PAs performing echocardiography (20.5%) and direct current cardioversion (11.9%), though concerns were raised about inadequate supervision and impact on resident training. 3
• This underscores the critical need for clear legal frameworks, defined scope of practice, and appropriate supervision to safeguard patient safety. 3

Clinical Integration

Established Role in Cardiothoracic Surgery

• Over a 30-year period at a university center, PA employment in cardiothoracic surgery expanded from 2 to 23 PAs, with duties including conduit harvesting, insertion of invasive catheters and chest tubes, surgical first assisting, and chest closure. 4
• The 50% retention rate and high job satisfaction (for PAs employed >12 months) demonstrates successful integration into cardiac surgical teams. 4

Medical Management Competencies

• All cardiovascular PAs should be able to evaluate and manage patients with ventricular arrhythmias, bradyarrhythmias, and heart block. 1
• PAs can recognize and medically manage specific wide complex tachycardias (monomorphic and polymorphic ventricular tachycardia). 1
• Skills to identify, evaluate, and manage patients at high risk for sudden cardiac death are expected. 1