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paroxysmal atrial fibrillation (PAF)

Atrial fibrillation that occurs episodically or in paroxysms. It stops spontaneously within 7 days of onset. [22] Labeled stage 3 atrial fibrillation [29] Epidemiology: - ~1/3 of high-risk patients with subclinical episodes of atrial fibrillation [12] - predictors of subclinical epsiodes of atrial fibrillation include: older age, left atrial enlargement, lower systolic BP Clinical manifestations: - episodes may be symptomatic, especially in patients with LV diastolic dysfunction, or asymptomatic (subclinical) - patients may be able to detect rhythm irregularity by monitoring their own pulse [10] - in one study, pulse measurements by relatives & competent patients had reasonable sensitivity & specificity compared with clinicians for detecting atrial fibirllation - clinicians: sensitivity of 97%, specificity of 94% - relatives: sensitivity of 77%, specificity of 93% - patients: sensitivity of 54%, specificity of 96% [10] - short asymptomatic episodes of paroxysmal atrial fibrillation, may occur in patients with dual-chamber pacemakers or implantable cardioverter-defibrillators (ICDs) [14] - smartphone applications can detect asymptomatic episodes of paroxysmal atrial fibrillation [14] - Fitbit can detect irregular heart rate - subsequent use of an ambulatory electrocardiogram patch can detect paroxysmal atrial fibrillation [24] Special laboratory: - in patients with cryptogenic stroke, HOLTER monitoring for a week or longer may identify patients with PAF [9] - home-based wearable ECG monitoring results in higher rate of paroxysmal atrial fibrillation diagnosis in high-risk individuals at 4 months [15] - annual 30-day monitoring with sensitivity of 34% for 1 year & 55% for 3 years in detecting paroxysmal atrial fibrillation [19] Complications: - progression to chronic atrial fibrillation [3,6] (9% in 1 year; 25% in 5 years; risk increases with age) - increases risk for ischemic stroke* (HR=5.6) [7] - absolute risk appears to be 1.5% over 5 years with median time to stroke of 8 months after ECG confirmation [13] - excess stroke risk highest within 5 days of an episode of atrial fibrillation of >= 5.5 hours & diminishes rapidly thereafter [21] - episodes of atrial fibrillation > 5 minutes increase risk of systemic embolic events - more time spent in atrial fibrillation associated with higher risk of embolic stroke [13] - short bursts of atrial fibrillation not associated with systemic embolic events [11] - progression of subclinical paroxysmal atrial fibrillation may be a harbinger of heart failure [14] - perioperative atrial fibrillation common, associated with similar risks for venous thromboembolism as new-onset atrial fibrillation & with similar crude rates of thromboembolism [16] - rapid ventricular response - if unstable, immediate synchronized cardioversion [28] * cryptogenic stroke Management: 1) anticoagulation & rhythm control (see atrial fibrillation) - calculate the CHA2DS2-VASc score, if 0 no anticoagulation 2) rhythm control for patients with new diagnosis within past 12 months or more [22,23] 3) atrial fibrillation duration of > 5 minutes & CHA2DS2-VASc scores >= 2 (men) >= 3 (women) would benefit from anticoagulation [17] 4) for device-detected atrial fibrillation lasting < 24 hours, risk of major bleeding outweighs risk reduction with anticoagulation for embolic stroke [25] 5) in patients with structural heart disease or major comorbidities, treat as symptomatic atrial fibrillation - cryoablation first line vs antiarrhythmic therapy [20] - reduces risk for persistent atrial fibrillation vs antiarrhythmic therapy [20] - radiofrequency catheter ablation - favorable effect on morbidity & mortality in patients with HFrEF [22] - pulmonary vein ablation [5] - risk of complications exceeds benefit, relative to antiarrhythmic agents [8] - pulse field ablation - see atrial fibriallation 6) pill-in-the-pocket may be appropriate for selected patients [1 ,2] - for transient, incidentally discovered atrial fibrillation, bleeding from anticoagulation about same as strokes prevented (< 2% in 3.5 years, comparison apixaban vs aspirin, mortality 18% both groups) [27] 7) fish oil 2 grams/day may suppress PAF (67% reduction) [4] - marine omega-3 fatty acids supplementation > 1 gram/day may increase risk of atrial fibrillation [26] 8) abstinence from alcohol reduces recurrences of atrial fibrillation lasting > 30 seconds (53% vs 73% ) & % of time spent in atrial fibrillation (0.5% vs 1.2%) [18] 9) elective surgery - target ventricular response for patients with chronic atrial fibrillation to undergo elective surgery is < 110/min [28] - see direct oral anticoagulant vs warfarin or perioperative anticoagulation if patient anticoagulated

General

atrial fibrillation (AF)

References

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