Treatment of paroxysmal atrial fibrillation

Attempt should be made to keep the patient in sinus rhythm. (1)

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.

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

Digoxin is of no benefit in paroxysmal atrial fibrillation.

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
  • in selected patients with paroxysmal AF and no structural heart disease left atrial ablation is reasonable as first-line therapy

Reference

1. Potpara T et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC)