What is Paroxysmal Atrial Fibrillation (PAF)?

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Last updated: March 13, 2025 • View editorial policy

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From the Guidelines

Paroxysmal atrial fibrillation (PAF) is a form of atrial fibrillation that occurs intermittently and resolves spontaneously, typically within 7 days, as defined by the 2011 ACCF/AHA/HRS guidelines 1.

Definition and Classification

PAF is designated when episodes of atrial fibrillation last 7 days or less, with most episodes lasting less than 24 hours, according to the 2011 ACCF/AHA/HRS guidelines 1. The definition and classification of PAF are crucial for determining the appropriate management strategy.

Pathophysiology

The pathophysiology of PAF involves repetitive rapid spontaneous focal activity commonly arising from myocyte sleeves within the pulmonary veins (PVs) or directly from the atrial muscle, as described in a 2024 narrative review on drug-induced atrial fibrillation 1. The electrical properties and complex fiber architecture of PVs can promote ectopic activity and re-entry, initiating AF.

Management

For management, I recommend a comprehensive approach including rate control, rhythm control, anticoagulation, and lifestyle modifications. First-line rate control medications include beta-blockers (metoprolol 25-100mg twice daily), calcium channel blockers (diltiazem 120-360mg daily), or digoxin (0.125-0.25mg daily). For rhythm control, options include flecainide (50-150mg twice daily), propafenone (150-300mg three times daily), or amiodarone (200mg daily after loading). Anticoagulation is crucial for stroke prevention, with options including warfarin (target INR 2-3), apixaban (5mg twice daily), rivaroxaban (20mg daily), or dabigatran (150mg twice daily). The CHA₂DS₂-VASc score should guide anticoagulation decisions, with therapy recommended for scores ≥2 in men or ≥3 in women. Catheter ablation may be considered for symptomatic patients who fail or cannot tolerate medication. Lifestyle modifications including weight loss, blood pressure control, sleep apnea treatment, and reducing alcohol consumption can significantly reduce PAF episodes by addressing underlying triggers and risk factors.

Key Considerations

Some key considerations in the management of PAF include:

  • The importance of characterizing the pattern of the arrhythmia as paroxysmal or persistent, determining its cause, and defining associated cardiac and extracardiac factors, as emphasized in the 2001 ACC/AHA/ESC guidelines 1.
  • The role of autonomic tone in the occurrence of PAF, with a primary increase in adrenergic activity followed by an abrupt shift toward vagal predominance, as described in the 2024 narrative review 1.
  • The potential for PAF to be triggered by various factors, including age, cardiovascular diseases, and risk factors, which can produce complex electrical and structural changes in the atria and/or PVs, as discussed in the 2024 narrative review 1.

From the Research

Definition of Paroxysmal Atrial Fibrillation (PAF)

  • Paroxysmal Atrial Fibrillation (PAF) is a type of atrial fibrillation that terminates spontaneously within seven days 2
  • It is a recurrent form of atrial fibrillation, characterized by episodes of irregular heart rhythm that stop on their own 3, 4

Characteristics of PAF

  • PAF is often symptomatic, and patients may experience palpitations, shortness of breath, and fatigue 4, 5
  • It can be triggered by various factors, including stress, caffeine, and certain medications 3
  • PAF can increase the risk of stroke, heart failure, and other cardiovascular complications if left untreated 3, 6

Treatment Options for PAF

  • Catheter ablation is a commonly used treatment for PAF, which involves using energy to destroy the abnormal electrical pathways in the heart 4, 2, 5
  • Antiarrhythmic medications can also be used to control symptoms and prevent recurrences 3, 4
  • Lifestyle modifications, such as reducing stress and avoiding triggers, can also help manage PAF symptoms 3

Outcomes and Prognosis

  • The success rate of catheter ablation for PAF varies depending on the patient population and the ablation technique used 4, 5
  • Studies have shown that catheter ablation can be effective in reducing symptoms and preventing recurrences in patients with PAF 4, 5, 6
  • The risk of complications, such as stroke and heart failure, can be reduced with proper treatment and management of PAF 3, 6

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

3
Research

Current management of symptomatic atrial fibrillation.

American journal of cardiovascular drugs : drugs, devices, and other interventions, 2001

4
Research

Should Ablation Be First-Line Therapy for Patients with Paroxysmal AF?

Current treatment options in cardiovascular medicine, 2017

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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