Paroxysmal Atrial Fibrillation (PAF)


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

  • 1st therapeutic intervention should be either a β-blocker or a class 1C anti-arrhythmic
  • 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 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 Amiodarone (class III agent) is the drug of choice


  • 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 ESC

Content by Dr Íomhar O' Sullivan. Last review Dr ÍOS 26/04/23.