What is the next step for a 7-year-old female patient with a recent hospitalization for suspected Atrial Fibrillation (AFib) who was found to be in sinus rhythm, and now presents with an Electrocardiogram (EKG) showing sinus rhythm with premature atrial complexes in a bigeminy pattern?

From the Guidelines

For a 7-year-old female patient with sinus rhythm and premature atrial complexes (PACs) in bigeminy pattern, the next step from a cardiology perspective should be a comprehensive cardiac evaluation, including a 24-hour Holter monitor and an echocardiogram, to assess cardiac structure and function, as recommended by the guidelines for the management of patients with supraventricular arrhythmias 1. This approach is crucial in determining if there is any underlying structural heart disease contributing to the arrhythmia. Given the patient's young age and recent hospitalization, referral to a pediatric cardiologist is appropriate for specialized assessment.

• The clinical history and physical examination are essential in evaluating patients with paroxysmal arrhythmias, as they are most often asymptomatic at the time of evaluation, and arrhythmia-related symptoms may include palpitations, fatigue, lightheadedness, chest discomfort, dyspnea, presyncope, or syncope 1.
• Premature beats are commonly described as pauses or nonconducted beats followed by a sensation of a strong heart beat, or they are described as irregularities in heart rhythm, and supraventricular tachycardias occur in all age groups and may be associated with minimal symptoms, such as palpitations, or they may present with syncope 1.
• In most cases, isolated PACs in children with structurally normal hearts are benign and do not require specific treatment, however, if the PACs are frequent or symptomatic (causing palpitations, dizziness, or chest discomfort), the cardiologist might consider beta-blockers such as propranolol (0.5-1 mg/kg/day divided into 2-3 doses) or atenolol (0.5-1 mg/kg once daily) 1.
• The family should be reassured that PACs in children are often a normal variant that may resolve spontaneously over time, particularly if cardiac structure is normal and the child is otherwise asymptomatic.
• It is also important to note that a clinical history describing the pattern in terms of the number of episodes, duration, frequency, mode of onset, and possible triggers is of crucial importance in clinical decision making, as it may yield important clues to the type of arrhythmia and guide further evaluation and treatment 1.

From the Research

Next Steps in Cardiology Perspective

The patient, a 7-year-old female, presents with sinus rhythm and premature atrial complexes in the pattern of bigeminy. Considering the evidence from the study 2, the following points are relevant:

• Premature atrial complexes (PACs) can increase the risk of adverse cardiovascular outcomes.
• Beta blockers at low dosages may help reduce PAC symptoms and improve long-term outcomes.
• The study found that beta blockers consistently decreased long-term mortality in both high-burden and low-burden patients.

Potential Treatment Options

Based on the study 2, potential next steps could include:

• Monitoring the patient's condition to determine the burden of PACs.
• Considering the use of beta blockers at low dosages to reduce PAC symptoms and improve long-term outcomes.
• Further evaluation and research to determine the best course of treatment for the patient.

Key Considerations

Key considerations in the patient's treatment include:

• The patient's age and overall health status.
• The frequency and burden of PACs.
• The potential benefits and risks of beta blocker treatment.
• The need for ongoing monitoring and evaluation to determine the effectiveness of treatment.