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
- 1st therapeutic intervention should be either:
- Class 1C anti-arrhythmic(eg. flecanide, propafenone), but only in a structurally normal heart. These have the highest reported success rate of preventing pAF
- β-blocker - relatively ineffective in these circumstances but have the advantage of being well tolerated
- 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 (eg. flecanide, propafenone) 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
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 Apixaban (or Warfarin) is appropriate
- Please refer to the algorithm suggested by the ESC