Rhythm control and cardioversion

The three main aims of treatment for paroxysmal atrial fibrillation are: (1) to suppress paroxysms of atrial fibrillation and maintain long-term sinus rhythm; (2) to control heart rate during paroxysms of atrial fibrillation if they occur; and (3) to prevent the complications associated with paroxysmal atrial fibrillation—that is, stroke and tachycardia-induced cardiomyopathy.1 Many patients with paroxysmal atrial fibrillation can be highly symptomatic, although asymptomatic paroxysms are common.2 However, the abolition of symptoms of paroxysmal atrial fibrillation does not necessarily mean abolition of the atrial fibrillation per se, as heart rate slowing may abolish symptoms but still allow asymptomatic episodes to continue.3 In some patients, it may be appropriate to document the frequency of arrhythmia by Holter monitoring or event recording. Of note, most pharmacological studies of paroxysmal atrial fibrillation have concentrated on the reduction of symptomatic recurrences of paroxysmal atrial fibrillation. If attacks of paroxysmal atrial fibrillation are frequent, current clinical practice usually uses chronic prophylaxis with drugs to reduce the frequency of paroxysms after removal of precipitating factors such as caffeine, alcohol, stress, and adequate treatment of underlying diseases such as myocardial ischaemia, thyrotoxicosis, and heart failure.1 In the long term, few patients achieve complete suppression of paroxysms of atrial fibrillation. Drug treatment for paroxysmal atrial fibrillation may be administered as prophylaxis against recurrent atrial fibrillation, but in those patients who are asymptomatic or have rare paroxysms (eg, only a few paroxysms a year) may decide not to take routine medication or to use a “pill-in-the-pocket” strategy, and the patient’s views need to be considered. Based on the systematic review undertaken as part of this guideline development, propafenone appears to be at least as effective as sotalol in preventing the recurrence of atrial fibrillation for up to 12 months following administration,4,5 although for …