Background
We agree with the recommendations in the Centre for Clinical Effectiveness document on management of Paroxysmal AF.
The European Society of Cardiology proffer:
No or minimal heart disease
- First therapeutic intervention should be either a β-blocker or a class 1C anti-arrhythmic drug
- β-blockers are relatively ineffective in these circumstances but have the advantage of being well tolerated.
- Class 1C antiarrhythmics have the highest reported success rate of preventing PAF.
- If class 1C and β-blockers fail, the class III agent, Amiodarone, should be the next
- When Amiodarone fails or is inappropriate, then ablation with rate control or pacing should be considered.
Presence of heart disease
- Management is much more difficult.
- Class 1C anti-arrhythmic drugs are not recommended (pro-arrhythmic).
- For some, β-blockers may be worth a trial
- For many the class III agent Amiodarone will be the drug of choice.
Thromboembolism
- In all categories, there is a risk of thrombi-embolism.
- The anti-arrhythmic strategy must be allied with consideration of the thromboembolic risk.
- In situations of moderate to high risk, oral Rivaroxaban (or Warfarin) is appropriate.
- Please refer to the algorithm suggested by the European Society of Cardiology.