treatment of paroxysmal atrial fibrillation

Last reviewed 05/2021

Attempt should be made to keep the patient in sinus rhythm.

If the patient is in atrial fibrillation then cardioversion is indicated. This may be achieved electrically - via cardioversion - or chemically - via antiarrhythmic drugs.

The frequency of relapse can be reduced by long-term administration of prophylactic antiarrhythmic drugs. In these patients Class I agents such as flecainide or propafenone - especially in patients with normal cardiac function - and Class III agents such as amiodarone (1).

Antithrombotic treatment is indicated as a long-term stroke prophylaxis.

Digoxin is of no benefit in paroxysmal atrial fibrillation (2).

Catheter ablation:

• paroxysmal atrial fibrillation can be eliminated long term by catheter ablation in 80-90% of patients, although 30-40% require a repeat procedure
  • at 5%, the risk of major complications compares favourably with long term antiarrhythmic treatment
  • threshold for catheter ablation should be low, and the guidance recommend catheter ablation after one or more antiarrhythmic drug has failed (3)
  • in selected patients with paroxysmal AF and no structural heart disease left atrial ablation is reasonable as first-line therapy (4)

More detailed information is included in the linked item below.

Reference:

1. The Practitioner 1999;243:746-51.
2. British Heart Foundation, Factfile 11/2000.
3. Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, et al. Guidelines for the management of atrial fibrillation: the task force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Europace2010;12:1360-420
4. Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, Hindricks G, Kirchhof P; ESC Committee for Practice Guidelines-CPG. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation - developed with the special contribution of the European Heart Rhythm Association. Europace. 2012 Oct;14(10):1385-413