1.

Paroxysmal atrial fibrillation (PAF), is defined as recurrent (two or more) episodes of AF that terminate spontaneously in less than seven days, usually less than 24 hours. It may be either self-terminating or intermittent. 2. In the Framingham Heart Study, the annual incidence of stroke in patients with PAF was 1.3 percent. 3. Several large trials have reported no difference in the risk of stroke between those with PAF and permanent AF . The following are two examples:

Among patients not on anticoagulation in SPAF, the yearly stroke rate was the same in PAF and permanent (or sustained) AF (5.6 versus 5.9 percent with no aspirin and 3.2 versus 3.3 percent on aspirin) in the different risk groups. Among the 24 percent of patients with PAF predicted to be at high risk, the rate of ischemic stroke was 7.8 percent per year. The Boston Area Anticoagulation Trial in Atrial Fibrillation (BAATAF) found a similar incidence of stroke in the two groups (13 versus 17 percent) for a yearly incidence of 2.5 percent and 2.8 percent, respectively

4. Additional evidence of the embolic risk associated with PAF comes from

AFFIRM and RACE trials that compared rhythm to rate control in patients with paroxysmal or permanent AF . Embolization occurred with equal frequency whether a rhythm control or a rate control strategy was adopted.

5. Among patients with paroxysmal AF, approximately 90 percent have recurrent

episodes of AF, and up to 90 percent of episodes are not detected by the patient. In addition, asymptomatic episodes lasting more than 48 hours are not uncommon, occurring in 17 percent of patients in a report using continuous monitoring. Thrombi can form during these prolonged episodes, possibly leading to clinical thromboembolism, although the precise relation to AF burden (that is, the duration of AF per day) to thromboembolism remains uncertain. Two studies evaluated the duration of time in AF after which a thromboembolic risk increases: one found after 5.5 hours and the other after 24 hours. Thus, patients with paroxysmal AF should be assessed for stroke risk and managed in a similar manner to sustained (persistent/permanent) AF. 6. The major risk models include:

The CHADS2 score, which was based upon independent clinical predictors from SPAF and AFI and then tested and validated in other cohorts The CHA2DS2-VASc score, which adds female sex, any vascular disease (prior myocardial infarction, peripheral artery disease, or aortic plaque), and age 65 to 74 years as risk factors as additional risk factors to the CHADS2 score.

The Stroke Prevention in Atrial Fibrillation (SPAF) investigators . The eighth American College of Chest Physicians (ACCP) Consensus Conference. The 2006 guidelines from the American College of Cardiology, the American Heart Association, and the European Society of Cardiology (ACC/AHA/ESC). A pooled analysis from the Atrial Fibrillation Investigators (AFI) .

These models agreed on the following high-risk features:

Prior embolic event Hypertension Older age

Other features were regarded as high risk in some, but not all, of the models:

Left ventricular systolic dysfunction or HF All models except that from the Framingham Heart Study Diabetes All models except SPAF Coronary artery disease The ACC/AHA/ESC guidelines Thyrotoxicosis The ACC/AHA/ESC guidelines Female sex The Framingham Study and, for women over the age of 75 years, SPAF and the ACC/AHA/ESC guidelines

Although the risk models discussed above are generally similar in terms of their moderate predictive ability, we believe that the CHADS2 score is the easiest to implement and most clinically useful model for risk stratification of patients with nonvalvular AF. For those patients with CHADS2 scores of 0 or 1, the additional use of CHA2DS2-VASc was recommended.

Warfarin anticoagulation titrated to an INR of 2.0-3.0 is recommended for the average patient with a CHA2DS2-VASc score 2 unless contraindicated (e.g., history of frequent falls, clinically significant bleeding, inability to obtain regular INR). Either Warfarin or Aspirin can be used for the average patient with a CHA2DS2-VASc score of 1 depending on physician discretion and patient preference. Aspirin 325 mg daily is recommended for the average patient with a CHA2DS2-VASc score of 0.