A 34-year-old man comes to the office for evaluation of premature atrial complexes found on a routine ECG. He has had no chest pain, shortness of breath, or lightheadedness. He has smoked 1-2 packs of cigarettes daily and consumed 1-2 beers a day for the past 10 years. The patient's family history is significant for a myocardial infarction in his mother at age 65 and a stroke in his father at age 72. He has no personal history of hypertension or diabetes. Physical examination, including vital signs, is within normal limits. What is the best next step in management of this patient?

Question

A 34-year-old man comes to the office for evaluation of premature atrial complexes found on a routine ECG.  He has had no chest pain, shortness of breath, or lightheadedness.  He has smoked 1-2 packs of cigarettes daily and consumed 1-2 beers a day for the past 10 years.  The patient's family history is significant for a myocardial infarction in his mother at age 65 and a stroke in his father at age 72.  He has no personal history of hypertension or diabetes.  Physical examination, including vital signs, is within normal limits.  What is the best next step in management of this patient?

Quizplus · Accepted Answer

Atrial premature beats, also called premature atrial complexes (PACs), occur when there is premature activation of the atria originating from a site other than the sinoatrial node. ECG will show an early P wave. PACs by themselves represent a benign arrhythmia that can occur both in healthy individuals and in patients with a variety of cardiovascular and systemic diseases. They may occur singly or in a pattern of bigeminy. PACs are usually asymptomatic; however, in some patients, they can cause symptoms of "skipped" beats or palpitations. Occasionally they can precede atrial fibrillation. Treatment is required only when symptoms cause distress or when there is supraventricular tachycardia. Even in asymptomatic patients, precipitating factors such as tobacco, alcohol, caffeine, and stress should be identified and avoided. premature atrial complexes (PACs) (Choice B) Holter monitoring is used in the outpatient setting to identify intermittent arrhythmias in patients with symptoms (eg, syncope, palpitations). This patient does not require Holter monitoring because he has an asymptomatic arrhythmia that has already been captured on ECG. (Choice C) In the absence of obvious precipitants (eg, caffeine, alcohol), a transthoracic echocardiogram is useful in patients with documented PACs to assess for any cardiac/valvular structural and/or functional abnormality. It would be of limited value in this patient because there is low suspicion for valvular disease, coronary artery disease, or heart failure (no edema or dyspnea). Most patients with alcoholic cardiomyopathy have a history of long-term (>5-10 years), excessive (eg, >7 drinks/day) alcohol consumption, unlike this patient. (Choice D) Reassurance alone is not appropriate as this patient has multiple modifiable risk factors for PACs. The patient can be reassured, however, that the condition itself is benign. (Choice E) Patients with persistent symptomatic PACs can be managed with low-dose beta blockers. Educational objective: Tobacco and alcohol are reversible risk factors for premature atrial contractions. Beta blockers are often helpful in symptomatic patients.

A 34-Year-Old Man Comes to the Office for Evaluation of Premature