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

  • 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.


  • 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.

Content by Dr Íomhar O' Sullivan. Last review Dr ÍOS 10/06/21.