What is the first-line treatment to achieve and maintain sinus rhythm in a 60-year-old man with symptomatic paroxysmal atrial fibrillation (AFib) who is not currently on any medication?

From the Guidelines

For a 60-year-old man with symptomatic paroxysmal atrial fibrillation, catheter ablation should be considered as a first-line treatment option to achieve and maintain sinus rhythm, as it has been shown to be effective in reducing AF-related symptoms and improving quality of life 1. When considering rhythm control, it's essential to weigh the benefits and risks of different treatment options, including cardioversion, antiarrhythmic drugs, and catheter or surgical ablation. According to the 2024 ESC guidelines for the management of atrial fibrillation 1, catheter ablation is recommended as a second-line option if antiarrhythmic drugs fail to control AF, or as a first-line option in patients with paroxysmal AF. Some key points to consider when evaluating the patient for catheter ablation include:

• Assessing the patient's symptoms and their impact on quality of life
• Evaluating the patient's medical history, including any comorbidities or risk factors for thromboembolism and bleeding
• Discussing the potential benefits and risks of catheter ablation with the patient, including the risk of complications and the potential need for repeat procedures
• Ensuring that the patient is aware of the importance of ongoing anticoagulation therapy, regardless of whether they are in AF or sinus rhythm 1. It's also important to note that the choice of treatment should be individualized based on the patient's specific needs and circumstances, and that a multidisciplinary team approach to care can help to ensure that the patient receives comprehensive and coordinated care 1.

From the FDA Drug Label

Sotalol AF are indicated for the maintenance of normal sinus rhythm [delay in time to recurrence of atrial fibrillation/atrial flutter (AFIB/AFL)] in patients with symptomatic AFIB/AFL who are currently in sinus rhythm. The first-line treatment to achieve and maintain sinus rhythm in a 60-year-old man with symptomatic paroxysmal atrial fibrillation (AFib) who is not currently on any medication is not explicitly stated in the provided drug labels.

• The labels discuss the use of Sotalol AF for maintaining normal sinus rhythm in patients with symptomatic AFIB/AFL who are currently in sinus rhythm, but do not provide information on achieving sinus rhythm in patients who are not currently in sinus rhythm.
• The labels do provide information on the efficacy of Sotalol AF in prolonging the time to recurrence of AFIB/AFL, but this is in the context of patients who are already in sinus rhythm.
• Therefore, no conclusion can be drawn about the first-line treatment to achieve and maintain sinus rhythm in this patient population based on the provided drug labels 2 2.

From the Research

First-Line Treatment for Symptomatic Paroxysmal Atrial Fibrillation

The first-line treatment to achieve and maintain sinus rhythm in a 60-year-old man with symptomatic paroxysmal atrial fibrillation (AFib) who is not currently on any medication is flecainide.

• Flecainide has been proven to be more effective than other antiarrhythmic drugs (AADs) for the acute termination of recent onset AF 3.
• It is also moderately effective and, with the exception of amiodarone, equivalent to other AADs for the chronic suppression of paroxysmal and persistent AF 3.
• In patients without structural heart disease, flecainide has been demonstrated to be safe and well tolerated relative to other AADs 3, 4.

Efficacy of Flecainide

• A study published in 1989 demonstrated that flecainide significantly reduced the rate of symptoms and PAF attacks in patients with paroxysmal atrial fibrillation 5.
• Another study published in 2023 showed that long-term therapy with flecainide had clinical efficacy in approximately half of the patients with paroxysmal or persistent AF 6.
• Flecainide has been shown to be effective in preventing symptomatic recurrences of paroxysmal atrial fibrillation, with a median time of 14.5 days to the first PAF attack on flecainide versus 3 days on placebo 5.

Safety of Flecainide

• Flecainide has been shown to be safe in the long-term treatment of patients with paroxysmal supraventricular tachyarrhythmias and without evidence of clinically significant heart disease 4.
• However, flecainide can cause proarrhythmic effects, which can lead to discontinuation of therapy 6.
• The safety of flecainide has been compared to propafenone in several studies, with similar results in terms of safety and efficacy 6, 4.