• Refer all people with paroxysmal atrial fibrillation (AF) to a cardiologist for management.
• While the person is waiting to see a specialist:
• Start either aspirin or warfarin (if they are not contraindicated), to reduce the person's risk of stroke.
• The choice of antithrombotic treatment should be based on the person's risk of stroke and not on the frequency or duration of paroxysms of AF.
• For further information, see Which antithrombotic treatment.
• If the person is having frequent, symptomatic paroxysms but does not require admission, consider starting a beta-blocker (unless this is contraindicated).
• Seek advice if uncertain whether to start drug treatment.
• For further information, see the prescribing section on beta-blockers.
• If a specialist initiates rhythm-control treatment, initial follow up and drug monitoring will be carried out by the specialist. However, primary healthcare professionals will be involved in the longer-term follow up (for example, monitoring of drugs and identifying complications of AF).

These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) guideline Atrial fibrillation: national clinical guideline for management in primary and secondary care [National Collaborating Centre for Chronic Conditions, 2006].

• The aims of treating paroxysmal atrial fibrillation (AF) are to prevent paroxysms of AF and maintain sinus rhythm, to control heart rate during paroxysms of AF, and to prevent complications (such as stroke).
• Drugs used to manage paroxysmal AF (such as amiodarone or sotalol) are not usually started in primary care; therefore, referral to a cardiologist is necessary.

Antithrombotic treatment

• Controlling the symptoms of paroxysmal AF does not necessarily mean abolition of the AF (asymptomatic episodes may still occur). Evidence indicates that people with paroxysmal AF are at the same risk of stroke as people with persistent or permanent AF and should be assessed in the same way as people with persistent AF.
• After reviewing limited evidence (subgroup analyses of two meta-analyses), NICE concluded that the efficacy of antithrombotic treatment in reducing the risk of ischaemic stroke is similar in people with paroxysmal AF and non-paroxysmal AF. The incidence of major bleeding was also similar between both groups.
• One meta-analysis (six randomized trials, 4052 participants) found that in people treated with aspirin, the incidence of stroke was similar in people with paroxysmal AF and non-paroxysmal AF [van Walraven et al, 2002].
• One meta-analysis (29 trials, 28,044 participants) found warfarin to be associated with a reduced incidence of ischaemic stroke compared with aspirin (1.5% compared to 4.7% respectively, p < 0.05) in people with AF [Hart et al, 2007]. These results were similar for people with paroxysmal AF and non-paroxysmal AF.

Rhythm-control treatment

• NICE recommends starting treatment with a standard beta-blocker to control frequent paroxysms of AF, especially if paroxysms are associated with symptoms. Therefore, starting a beta-blocker in primary care will help reduce the number of paroxysms, help with symptoms, and possibly maintain sinus rhythm while awaiting specialist assessment.

Follow up

• The specialist will usually follow up the person to assess whether they are still continuing to have paroxysms of AF and determine whether further treatment is necessary.