Paroxysmal Atrial Fibrillation: When Rate Control Does Not Achieve the Target
This protocol applies to patients with paroxysmal atrial fibrillation — episodes that terminate spontaneously within 7 days or with the assistance of an intervention — in whom initial rate control has not brought the resting heart rate below 110 b.p.m., or in whom symptoms continue despite that rate target being met.
Paroxysmal AF terminates spontaneously within 7 days. When rate control alone is insufficient, the management goal shifts to maintenance of sinus rhythm and reduction of AF-related symptoms.
Prior therapy — rate control with a single agent (a beta-blocker or digoxin when LVEF ≤40%; a beta-blocker, digoxin, diltiazem, or verapamil when LVEF >40%) — did not achieve a resting heart rate below 110 b.p.m., or symptoms persisted despite rate targets being met. This is the condition that triggers escalation to the current protocol.
The next step is a rhythm control strategy. This may involve antiarrhythmic drug therapy — the agent selected according to the patient's underlying cardiac profile — or, in appropriate patients, a catheter-based intervention as a first-line option. The full selection algorithm and patient-specific criteria are available in the complete protocol.
References
DOI: 10.1093/eurheartj/ehae176
- AF which terminates spontaneously within 7 days or with the assistance of an intervention.
- Catheter ablation is recommended as a first-line option within a shared decision-making rhythm control strategy in patients with paroxysmal AF, to reduce symptoms, recurrence, and progression of AF.