Paroxysmal atrial fibrillation
- Philip J Podrid, MD, FACC
Philip J Podrid, MD, FACC
- Professor of Medicine, Professor of Pharmacology and Experimental Therapeutics
- Boston University School of Medicine
- Lecturer, Harvard Medical School
Atrial fibrillation (AF) is the most common arrhythmia lasting for more than 30 seconds. Its prevalence in the population increases with age, and it is estimated to affect over 4 percent of the population above the age of 60 [1-3]. (See "Epidemiology of and risk factors for atrial fibrillation", section on 'Epidemiology'.)
Paroxysmal AF (PAF), also termed intermittent AF, is defined as an episode of AF that terminates spontaneously or with intervention in less than seven days . "Persistent," "longstanding persistent," and "permanent" are clinical labels used for the other types of AF. (See "Overview of atrial fibrillation".)
This definition applies to recurrent intermittent episodes of AF that are unrelated to a reversible cause. If the AF is secondary to cardiac surgery, pericarditis, myocardial infarction, hyperthyroidism, pulmonary embolism, pulmonary disease, or other reversible causes, therapy is directed toward the underlying disease as well as the AF. (See "Epidemiology of and risk factors for atrial fibrillation".)
This topic will address the ways in which patients with PAF differ from the broad population of patients with AF. However, in many instances, patients with PAF are managed in a manner similar to those with more sustained forms of AF.
- Halperin JL, Hart RG. Atrial fibrillation and stroke: new ideas, persisting dilemmas. Stroke 1988; 19:937.
- Kannel WB, Abbott RD, Savage DD, McNamara PM. Epidemiologic features of chronic atrial fibrillation: the Framingham study. N Engl J Med 1982; 306:1018.
- Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation: a major contributor to stroke in the elderly. The Framingham Study. Arch Intern Med 1987; 147:1561.
- January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014; 64:e1.
- Israel CW, Grönefeld G, Ehrlich JR, et al. Long-term risk of recurrent atrial fibrillation as documented by an implantable monitoring device: implications for optimal patient care. J Am Coll Cardiol 2004; 43:47.
- Page RL, Wilkinson WE, Clair WK, et al. Asymptomatic arrhythmias in patients with symptomatic paroxysmal atrial fibrillation and paroxysmal supraventricular tachycardia. Circulation 1994; 89:224.
- Chen SA, Hsieh MH, Tai CT, et al. Initiation of atrial fibrillation by ectopic beats originating from the pulmonary veins: electrophysiological characteristics, pharmacological responses, and effects of radiofrequency ablation. Circulation 1999; 100:1879.
- Haïssaguerre M, Jaïs P, Shah DC, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998; 339:659.
- Kolb C, Nürnberger S, Ndrepepa G, et al. Modes of initiation of paroxysmal atrial fibrillation from analysis of spontaneously occurring episodes using a 12-lead Holter monitoring system. Am J Cardiol 2001; 88:853.
- Dewland TA, Vittinghoff E, Mandyam MC, et al. Atrial ectopy as a predictor of incident atrial fibrillation: a cohort study. Ann Intern Med 2013; 159:721.
- Sauer WH, Alonso C, Zado E, et al. Atrioventricular nodal reentrant tachycardia in patients referred for atrial fibrillation ablation: response to ablation that incorporates slow-pathway modification. Circulation 2006; 114:191.
- Hwang C, Wu TJ, Doshi RN, et al. Vein of marshall cannulation for the analysis of electrical activity in patients with focal atrial fibrillation. Circulation 2000; 101:1503.
- Lin WS, Tai CT, Hsieh MH, et al. Catheter ablation of paroxysmal atrial fibrillation initiated by non-pulmonary vein ectopy. Circulation 2003; 107:3176.
- Coumel P. Autonomic influences in atrial tachyarrhythmias. J Cardiovasc Electrophysiol 1996; 7:999.
- Coumel P. Cardiac arrhythmias and the autonomic nervous system. J Cardiovasc Electrophysiol 1993; 4:338.
- Herweg B, Dalal P, Nagy B, Schweitzer P. Power spectral analysis of heart period variability of preceding sinus rhythm before initiation of paroxysmal atrial fibrillation. Am J Cardiol 1998; 82:869.
- Elvan A, Pride HP, Eble JN, Zipes DP. Radiofrequency catheter ablation of the atria reduces inducibility and duration of atrial fibrillation in dogs. Circulation 1995; 91:2235.
- Brignole M, Gianfranchi L, Menozzi C, et al. Role of autonomic reflexes in syncope associated with paroxysmal atrial fibrillation. J Am Coll Cardiol 1993; 22:1123.
- Graboys TB, Wright RF. Provocation of supraventricular tachycardia during exercise stress testing. Cardiovasc Rev Rep 1980; 1:57.
- de Vos CB, Nieuwlaat R, Crijns HJ, et al. Autonomic trigger patterns and anti-arrhythmic treatment of paroxysmal atrial fibrillation: data from the Euro Heart Survey. Eur Heart J 2008; 29:632.
- Rosso R, Sparks PB, Morton JB, et al. Vagal paroxysmal atrial fibrillation: prevalence and ablation outcome in patients without structural heart disease. J Cardiovasc Electrophysiol 2010; 21:489.
- Coplen SE, Antman EM, Berlin JA, et al. Efficacy and safety of quinidine therapy for maintenance of sinus rhythm after cardioversion. A meta-analysis of randomized control trials. Circulation 1990; 82:1106.
- Rostagno C, Bacci F, Martelli M, et al. Clinical course of lone atrial fibrillation since first symptomatic arrhythmic episode. Am J Cardiol 1995; 76:837.
- Davidson E, Weinberger I, Rotenberg Z, et al. Atrial fibrillation. Cause and time of onset. Arch Intern Med 1989; 149:457.
- Takahashi N, Seki A, Imataka K, Fujii J. Clinical features of paroxysmal atrial fibrillation. An observation of 94 patients. Jpn Heart J 1981; 22:143.
- Kerr CR, Humphries KH, Talajic M, et al. Progression to chronic atrial fibrillation after the initial diagnosis of paroxysmal atrial fibrillation: results from the Canadian Registry of Atrial Fibrillation. Am Heart J 2005; 149:489.
- Flaker GC, Fletcher KA, Rothbart RM, et al. Clinical and echocardiographic features of intermittent atrial fibrillation that predict recurrent atrial fibrillation. Stroke Prevention in Atrial Fibrillation (SPAF) Investigators. Am J Cardiol 1995; 76:355.
- Al-Khatib SM, Wilkinson WE, Sanders LL, et al. Observations on the transition from intermittent to permanent atrial fibrillation. Am Heart J 2000; 140:142.
- Godtfredsen J. Atrial fibrillation — Etiology, course and prognosis: A followup of 1212 patients, University of Denmark, Copenhagen 1975.
- Aboaf AP, Wolf PS. Paroxysmal atrial fibrillation. A common but neglected entity. Arch Intern Med 1996; 156:362.
- Petersen P, Godtfredsen J. Atrial fibrillation--a review of course and prognosis. Acta Med Scand 1984; 216:5.
- Friberg L, Hammar N, Pettersson H, Rosenqvist M. Increased mortality in paroxysmal atrial fibrillation: report from the Stockholm Cohort-Study of Atrial Fibrillation (SCAF). Eur Heart J 2007; 28:2346.
- Wann LS, Curtis AB, January CT, et al. 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (Updating the 2006 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2011; 57:223.
- Calkins H, Reynolds MR, Spector P, et al. Treatment of atrial fibrillation with antiarrhythmic drugs or radiofrequency ablation: two systematic literature reviews and meta-analyses. Circ Arrhythm Electrophysiol 2009; 2:349.
- Stabile G, Bertaglia E, Senatore G, et al. Catheter ablation treatment in patients with drug-refractory atrial fibrillation: a prospective, multi-centre, randomized, controlled study (Catheter Ablation For The Cure Of Atrial Fibrillation Study). Eur Heart J 2006; 27:216.
- Morillo CA, Verma A, Connolly SJ, et al. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation (RAAFT-2): a randomized trial. JAMA 2014; 311:692.
- Cosedis Nielsen J, Johannessen A, Raatikainen P, et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med 2012; 367:1587.
- Wilber DJ, Pappone C, Neuzil P, et al. Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial. JAMA 2010; 303:333.
- Hakalahti A, Biancari F, Nielsen JC, Raatikainen MJ. Radiofrequency ablation vs. antiarrhythmic drug therapy as first line treatment of symptomatic atrial fibrillation: systematic review and meta-analysis. Europace 2015; 17:370.
- Nielsen JC, Johannessen A, Raatikainen P, et al. Long-term efficacy of catheter ablation as first-line therapy for paroxysmal atrial fibrillation: 5-year outcome in a randomised clinical trial. Heart 2016.
- Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:2893.
- Lakkireddy D, Atkins D, Pillarisetti J, et al. Effect of yoga on arrhythmia burden, anxiety, depression, and quality of life in paroxysmal atrial fibrillation: the YOGA My Heart Study. J Am Coll Cardiol 2013; 61:1177.
- Hart RG, Pearce LA, Rothbart RM, et al. Stroke with intermittent atrial fibrillation: incidence and predictors during aspirin therapy. Stroke Prevention in Atrial Fibrillation Investigators. J Am Coll Cardiol 2000; 35:183.
- The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation. The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators. N Engl J Med 1990; 323:1505.
- Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med 1994; 154:1449.
- van Walraven C, Hart RG, Singer DE, et al. Oral anticoagulants vs aspirin in nonvalvular atrial fibrillation: an individual patient meta-analysis. JAMA 2002; 288:2441.
- Singer DE, Albers GW, Dalen JE, et al. Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:546S.
- SIGNS AND SYMPTOMS OF AF
- Atrial premature beats
- Autonomic dysfunction
- NATURAL HISTORY
- Recurrence of AF
- Progression to persistent or permanent AF
- Risk of embolization
- MANAGEMENT OF THE ARRHYTHMIA
- Acute therapy
- Prevention of recurrence
- Rate control