Prophylaxis versus paroxysms of atrial fibrillation

Requires specialist advice

This description of suggested pharmacological management is from a previous NICE guideline (1):

• if a patient has infrequent paroxysms and few symptoms, or where symptoms are induced by known precipitants (such as alcohol, caffeine)
  • a 'no drug treatment' strategy or a 'pill-in-the-pocket' strategy (a drug management strategy for paroxysmal AF in which the patient self-administers antiarrhythmic drugs only upon the onset of an episode of AF) should be considered and discussed with the patient
    
    
• patients with symptomatic paroxysms (with or without structural heart disease, including coronary artery disease)
  • a standard beta-blocker should be the initial treatment option
    
    
• in patients with paroxysmal AF and no structural heart disease:
  • where symptomatic suppression is not achieved with standard beta-blockers, either
    • a Class Ic agent (such as flecainide or propafenone) or
    • sotalol should be given
  • where symptomatic suppression is not achieved with standard beta-blockers, Class Ic agents or sotalol, either
    • amiodarone or
    • referral for non-pharmacological intervention should be considered
      
      
• patients with paroxysmal AF and coronary artery disease:
  • where standard beta-blockers do not achieve symptomatic suppression, sotalol should be given
  • where neither standard beta-blockers nor sotalol achieve symptomatic suppression, either
    • amiodarone or
    • referral for non-pharmacological intervention should be considered
      
      
• patients with paroxysmal AF with poor left ventricular function:
  • where standard beta-blockers are given as part of the routine management strategy and adequately suppress paroxysms, no further treatment for paroxysms is needed
  • where standard beta-blockers do not adequately suppress paroxysms, either
    • amiodarone or
    • referral for non-pharmacological intervention should be considered
      
      
• patients on long-term medication for paroxysmal AF should be kept under review to assess the need for continued treatment and the development of any adverse effects

NICE state (4):

• "..where patients have infrequent paroxysms and few symptoms, or where symptoms are induced by known precipitants (such as alcohol, caffeine), a 'no drug treatment' strategy or a 'pill-in-the-pocket' strategy should be considered and discussed with the patient.."
  
  
• in people with paroxysmal atrial fibrillation, a 'pill-in-the-pocket' strategy should be considered for those who:
  • have no history of left ventricular dysfunction, or valvular or ischaemic heart disease and
  • have a history of infrequent symptomatic episodes of paroxysmal atrial fibrillation and
  • have a systolic blood pressure greater than 100 mmHg and a resting heart rate above 70 bpm and
  • are able to understand how to, and when to, take the medication
    
    
• pace and ablate strategy
  • consider left atrial catheter ablation before pacing and atrioventricular node ablation for people with paroxysmal atrial fibrillation or heart failure caused by non-permanent (paroxysmal or persistent) atrial fibrillation
    
    
• left atrial ablation
  • if drug treatment is unsuccessful, unsuitable or not tolerated in people with symptomatic paroxysmal or persistent atrial fibrillation:
    • consider radiofrequency point-by-point ablation or
    • if radiofrequency point-by-point ablation is assessed as being unsuitable, consider cryoballoon ablation or laser balloon ablation
  • consider left atrial surgical ablation at the same time as other cardiothoracic surgery for people with symptomatic atrial fibrillation

Notes:

• catheter ablation (2,3):
  • 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 (2)
  • in selected patients with paroxysmal AF and no structural heart disease left atrial ablation is reasonable as first-line therapy (3)
    
    
• preventing recurrence after ablation (4)
  • consider antiarrhythmic drug treatment for 3 months after left atrial ablation to prevent recurrence of atrial fibrillation, taking into account the person's preferences, and the risks and potential benefits
  • reassess the need for antiarrhythmic drug treatment at 3 months after left atrial ablation

Reference:

1. NICE (June 2006). Atrial Fibrillation
2. Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, et al. Guidelines for the management of atrial fibrillation: the task force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Europace2010;12:1360-420
3. Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, Hindricks G, Kirchhof P; ESC Committee for Practice Guidelines-CPG. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation - developed with the special contribution of the European Heart Rhythm Association. Europace. 2012 Oct;14(10):1385-413
4. NICE (April 2021). Atrial Fibrillation