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   MeshID        = D018880 |
   MeshID        = D018880 |
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{{SI}}
{{premature atrial contraction}}
{{CMG}}; {{AE}} {{CZ}}  
{{CMG}}; {{AE}} {{CZ}}; {{M.P}}


{{SK}} PAC; PACs; premature atrial contractions; premature atrial complex; premature atrial complexes; APC; APCs; atrial premature contraction; atrial premature contractions; atrial premature complex; atrial premature complexes; APB; atrial premature beat; atrial premature beats; extrasystole, atrial; premature atrial beat; premature atrial beats; premature supraventricular beat; premature supraventricular beats
{{SK}} PAC, PACs, premature atrial contractions, premature atrial complex, premature atrial complexes, APC, APCs, atrial premature contraction, atrial premature contractions, atrial premature complex, atrial premature complexes, APB, atrial premature beat, atrial premature beats, extrasystole, premature atrial beat, premature atrial beats, premature supraventricular beat, premature supraventricular beat


==Overview==
==[[Premature atrial contraction overview|Overview]]==
'''Premature atrial contractions'''  is a benign type of premature heart beat which originates in one of the upper two chambers of the heart (the [[Atrium (heart)|atria]]). PACs usually reflect one of the conditions listed in the differential diagnosis of underlying causes below, and the treatment involves removing or treating the underlying cause.
PACs are to be distinguished from [[premature ventricular contractions]] ([[PVCs]]) that originate in one of the lower pumping chambers (the ventricles).


==Causes==
==[[Premature atrial contraction historical perspective|Historical Perspective]]==
===Life Threatening Causes===
*[[Heart transplantation|Acute cardiac allograft rejection]]
*[[Myocardial infarction]]
*[[Pulmonary embolism]]
*[[STEMI]]
*[[Thyrotoxicosis]]


===Common Causes===
==[[Premature atrial contraction classification|Classification]]==
*[[Coronary heart disease]]
*[[Dehydration]]
*[[Hypokalemia]]
*[[Hypomagnesemia]]
*[[Pneumonia]]


===Causes by Organ System===
==[[Premature atrial contraction pathophysiology|Pathophysiology]]==
{|style="width:80%; height:100px" border="1"
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[Congenital heart disease]], [[congestive heart failure]], [[coronary heart disease]], [[holiday heart syndrome]], [[hypertensive heart disease]], [[hypertrophic cardiomyopathy]], [[mitral regurgitation]], [[mitral stenosis]], [[mitral valve prolapse]], [[myocardial infarction]], [[myocarditis]], [[STEMI]], [[valvular heart disease]]
|-
|-bgcolor="LightSteelBlue"
| '''Chemical / poisoning'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dermatologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
|bgcolor="Beige"| [[Alpha interferon]], [[aminophylline]], [[amiodarone]], [[amlodipine]], [[amphetamines]], [[cocaine]], [[digoxin]], [[diltiazem]], [[dobutamine]], [[ephedrine]], [[5-fluorouracil]], [[isoproterenol]], [[phenylephrine]], [[salbutamol]], [[tacrolimus]], [[theophylline]], [[thiazides]], [[verapamil]]
|-
|-bgcolor="LightSteelBlue"
| '''Ear Nose Throat'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Endocrine'''
|bgcolor="Beige"| [[Metabolic syndrome]], [[hyperthyroidism|subclinical hyperthyroidism]], [[thyrotoxicosis]]
|-
|-bgcolor="LightSteelBlue"
| '''Environmental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Genetic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Hematologic'''
|bgcolor="Beige"|
|-
|-bgcolor="LightSteelBlue"
| '''Iatrogenic'''
|bgcolor="Beige"| [[Heart transplantation|Acute cardiac allograft rejection]], [[cardiac stress test]], [[cardiac transplantation]], [[cardioversion]], [[Artificial pacemaker|pacemaker malfunction]], [[transjugular intrahepatic portosystemic shunts]]
|-
|-bgcolor="LightSteelBlue"
| '''Infectious Disease'''
|bgcolor="Beige"| [[Myocarditis]]
|-
|-bgcolor="LightSteelBlue"
| '''Musculoskeletal / Ortho'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Neurologic'''
|bgcolor="Beige"| [[Subarachnoid hemorrhage]]
|-
|-bgcolor="LightSteelBlue"
| '''Nutritional / Metabolic'''
|bgcolor="Beige"| [[Dehydration]], [[electrolyte disturbance]], [[hypokalemia]], [[hypomagnesemia]]
|-
|-bgcolor="LightSteelBlue"
| '''Obstetric/Gynecologic'''
|bgcolor="Beige"| [[Infant|New born]]
|-
|-bgcolor="LightSteelBlue"
| '''Oncologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Opthalmologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Overdose / Toxicity'''
|bgcolor="Beige"| [[Amphetamines]], [[cocaine]], [[digoxin]], [[cannabis]]
|-
|-bgcolor="LightSteelBlue"
| '''Psychiatric'''
|bgcolor="Beige"| [[Anxiety disorders]], [[bulimia nervosa]], [[Takotsubo cardiomyopathy]]
|-
|-bgcolor="LightSteelBlue"
| '''Pulmonary'''
|bgcolor="Beige"| [[restrictive lung disease|chronic lung disease]], [[COPD]], [[hypoxia]], [[pulmonary embolism]], [[hypercapnia]], [[respiratory acidosis]], [[pneumonia]], [[pulmonary hypertension]], [[obstructive sleep apnea]]
|-
|-bgcolor="LightSteelBlue"
| '''Renal / Electrolyte'''
|bgcolor="Beige"| [[Chronic renal failure]]
|-
|-bgcolor="LightSteelBlue"
| '''Rheum / Immune / Allergy'''
|bgcolor="Beige"| [[Heart transplantation|Acute cardiac allograft rejection]]
|-
|-bgcolor="LightSteelBlue"
| '''Sexual'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Trauma'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Urologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Miscellaneous'''
|bgcolor="Beige"| [[Alcohol]], [[caffeine]], [[chocolate]], [[exercise|heavy exercise]], [[fatigue]], [[fever]], [[idiopathic]], [[stress]]
|-
|}


===Causes in Alphabetical Order===
==[[Premature atrial contraction causes|Causes]]==
{{col-begin|width=80%}}
{{col-break|width=33%}}
*[[Heart transplantation|Acute cardiac allograft rejection]]
*[[Alcohol]]
*[[Alpha interferon]]
*[[Amiodarone]]
*[[Aminophylline]]
*[[Amlodipine]]
*[[Amphetamines]]
*[[Anemia]]
*[[Anxiety]]
*[[Bulimia nervosa]]
*[[Caffeine]]
*[[Cannabis]]
*[[Cardiac stress test]]
*[[Cardiac transplantation]]
*[[Cardioversion]]
*[[Chocolate]]
*[[restrictive lung disease|Chronic lung disease]]
*[[Chronic renal failure]]
*[[Cocaine]]
*[[Congenital heart disease]]
*[[Congestive heart failure]]
*[[COPD]]
*[[Coronary heart disease]]
*[[Dehydration]]
{{col-break|width=33%}}
*[[Diltiazem]]
*[[Digoxin]]
*[[Dobutamine]]
*[[Electrolyte disturbance]]
*[[Ephedrine]]
*[[Fatigue]]
*[[Fever]]
*[[5-fluorouracil]]
*[[exercise|Heavy exercise]]
*[[Holiday heart syndrome]]
*[[Hypercapnia]]
*[[Hypertensive heart disease]]
*[[Hypertrophic cardiomyopathy]]
*[[Hypokalemia]]
*[[Hypomagnesemia]]
*[[Hypoxia]]
*[[Idiopathic]]
*[[Isoproterenol]]
*[[Metabolic syndrome]]
*[[Mitral regurgitation]]
*[[Mitral stenosis]]
*[[Mitral valve prolapse]]
*[[Myocardial infarction]]


{{col-break|width=33%}}
==[[Premature atrial contraction differential diagnosis|Differentiating Premature atrial contraction from other Diseases]]==
*[[Myocarditis]]
*[[Infant|New born]]
*[[Obstructive sleep apnea]]
*[[Artificial pacemaker|Pacemaker malfunction]]
*[[Phenylephrine]]
*[[Pneumonia]]
*[[Pulmonary embolism]]
*[[Pulmonary hypertension]]
*[[Respiratory acidosis]]
*[[Salbutamol]]
*[[STEMI]]
*[[Stress]]
*[[Subarachnoid hemorrhage]]
*[[hyperthyroidism|Subclinical hyperthyroidism]]
*[[Tacrolimus]]
*[[Takotsubo cardiomyopathy]]
*[[Theophylline]]
*[[Thiazides]]
*[[Thyrotoxicosis]]
*[[Transjugular intrahepatic portosystemic shunts]]
*[[Valvular heart disease]]
*[[Verapamil]]
{{col-end}}


==Prognosis==
==[[Premature atrial contraction epidemiology and demographics|Epidemiology and Demographics]]==
In general the prognosis of PACs is good, and their occurrence and prognosis is determined by the underlying condition that triggered the PACs. In rare cases, a PAC can, like a PVC, trigger a more serious arrhythmia such as [[atrial flutter]] or [[atrial fibrillation]].  Unlike PVC's, PAC's generally do not cause hemodynamic compromise because the conduction throughout the [[AV node]] and ventricles is normal, and the filling and contraction of the heart is therefore normal.


==Diagnosis==
==[[Premature atrial contraction risk factors|Risk Factors]]==
===Symptoms===
There may be a sense of "a skipped beat" or "a thump in the chest" or neck. In many cases, the person feels nothing.


===Physical Examination===
==[[Premature atrial contraction screening|Screening]]==
====Pulse====
The pulse may feel irregular in a patient who actively has frequent PACs.


===Laboratory Findings===
==[[Premature atrial contraction natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
* Consider checking [[Thyroid Function Test]]s to rule out [[hyperthyroidism]]
* Consider checking hemoglobin and [[hematocrit]] to rule out [[anemia]]


===Electrocardiogram===
==Diagnosis==
The presence of PACs is diagnosed based upon either an [[Electrocardiogram|EKG]], Holter, or Cardiac Event Monitor.
[[Premature atrial contraction diagnostic study of choice|Diagnostic study of choice]] | [[Premature atrial contraction history and symptoms|History and Symptoms]] | [[Premature atrial contraction physical examination|Physical Examination]] | [[Premature atrial contraction laboratory findings|Laboratory Findings]] | [[Premature atrial contraction electrocardiogram|Electrocardiogram]] | [[Premature atrial contraction x ray|X-Ray Findings]] | [[Premature atrial contraction echocardiography|Echocardiography]] | [[Premature atrial contraction CT scan|CT-Scan Findings] | [[Premature atrial contraction MRI|MRI Findings]] | [[Premature atrial contraction cardiac catheterization|Cardiac Catheterization]] | [[Premature atrial contraction other imaging findings|Other Imaging Findings]] | [[Premature atrial contraction other diagnostic studies|Other Diagnostic Studies]]


# By definition the [[P wave]]s are premature
==Treatment==
# Morphology of the P' wave is different than the [[P wave]] in [[normal sinus rhythm]]. If its origin is close to that of the sinus node, then the P' morphology is hard to distinguish from the native sinus P wave.
[[Premature atrial contraction medical therapy|Medical Therapy]] | [[Premature atrial contraction interventions|Interventions]] | [[Premature atrial contraction surgery|Surgery]] | [[Premature atrial contraction primary prevention|Primary Prevention]] | [[Premature atrial contraction secondary prevention|Secondary Prevention]] | [[Premature atrial contraction cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Premature atrial contraction future or investigational therapies|Future or Investigational Therapies]]
# A PAC differs from a [[Premature Junctional Contraction]] (PJC) in that the [[PR interval]] is > 0.12 second in a PAC.
# The PR interval may be shorter than that in [[Normal Sinus Rhythm]] ([[NSR]]) if it is located closer to the AV node.
# The PR interval tends to lengthen when the coupling time to the PAC is short.
# A PAC may not be conducted to the ventricles and this is called a blocked PAC.
#* The differential diagnosis in this scenario includes second degree [[AV block]]. In second degree AV block, the PP intervals remain constant.
# Usually the QRS is of normal duration, but occasionally there is aberrant conduction, most frequently of [[Right Bundle Branch Block]] (RBBB) morphology.
#* Aberrancy is more likely to occur when the coupling time is shorter.
# Usually there is no compensatory pause. The PAC resets the [[sinus node]].
# Most of these patients do not have organic heart disease.
#* 64% of healthy subjects will have PACs on 24 hour [[Holter monitoring]].
#* Frequency higher in the elderly
# The QRS complex is normal
# There is normal [[T wave]] repolarization (not inverted to the other T waves)
{{#ev:youtube|KPN1Jgf7hfM}}
 
===EKG Examples===
----
Shown below is an example of an EKG showing sinus rhythm with atrial premature beats in trigemini.
[[Image:Rhythm_premature.png|center|500px]]
Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/File:Rhythm_premature.png
----
 
Shown below is an example of an EKG showing premature atrial contractions with evident negative p-wave.
[[Image:Bes.png|center|800px]]
Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/File:Bes.png
----
 
Shown below is an example of a 12 lead EKG showing premature atrial contractions in a patient with [[RBBB]] + [[LAFB]]
[[Image:Bifascicular1.jpg|center|800px]]
Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
----
 
Shown below is an EKG showing [[sinus rhythm]] with atrial premature beats in trigemini.
[[File:PrematureatrialbeatstrigeminiEKG.jpg|center|800px]]
Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/File:E287.jpg
----


Shown below is an EKG showing sinus rhythm with premature atrial complexes. The P' wave can be seen deforming the T wave in the lead II rhythm strip. Note also that the atrial premature complexes reset the sinus node and hence there is no compensatory pause before the next sinus P wave. The QRS is deformed with a rsR' in V1 and a broad S in I with a duration of > 120 ms. diagnostic of aberrance with a right bundle branch morphology. The S1 Q3 and the right ward axis of the aberrant complexes suggest an additional [[left posterior fasicular block]].
==Case Studies==
[[File:Premature atrial complexes1.jpg|center|800px]]
Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/File:E000746.jpg
----


Shown below is an EKG showing an atrial premature beat (3rd beat). In fact note the QT interval of the second beat is short and in fact this was an artifact from a paper jam in the EKG recorder. The EKG also shows a first degree A/V block and abnormal Q waves in the inferior and anterior leads consistent with inferior and anterior myocardial infarctions which are probably old.
[[Premature atrial contraction case study one|Case #1]]
[[File:Premature atrial complexes2.jpg|center|800px]]
Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/File:E281.jpg
----


==Treatment==
==Related Chapters==
Removal or treatment of the underlying cause of PACs listed in the differential diagnosis is generally sufficient.  [[Beta-blockers]] may be helpful if the patient remains symptomatic.
* [[Tachycardia]]
* [[Atrial fibrillation]]
* [[SVT|Supraventricular arrthymia]]


==References==
{{Reflist|2}}


{{Electrocardiography}}
{{Circulatory system pathology}}


[[Category:Electrophysiology]]
[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Up-To-Date cardiology]]
[[Category:Up-To-Date]]
[[Category:Arrhythmia]]


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Latest revision as of 21:19, 15 April 2020

Premature atrial contraction
12 lead EKG shows Premature Atrial Contractions and bifascicular block (RBBB + LAFB)
ICD-10 I49.1
ICD-9 427.61
MeSH D018880

Premature atrial contraction Microchapters

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Overview

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Mugilan Poongkunran M.B.B.S [3]

Synonyms and keywords: PAC, PACs, premature atrial contractions, premature atrial complex, premature atrial complexes, APC, APCs, atrial premature contraction, atrial premature contractions, atrial premature complex, atrial premature complexes, APB, atrial premature beat, atrial premature beats, extrasystole, premature atrial beat, premature atrial beats, premature supraventricular beat, premature supraventricular beat

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Premature atrial contraction from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic study of choice | History and Symptoms | Physical Examination | Laboratory Findings | Electrocardiogram | X-Ray Findings | Echocardiography | [[Premature atrial contraction CT scan|CT-Scan Findings] | MRI Findings | Cardiac Catheterization | Other Imaging Findings | Other Diagnostic Studies

Treatment

Medical Therapy | Interventions | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

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Case #1

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