Intended for healthcare professionals

Practice Easily Missed?

Paroxysmal atrial fibrillation

BMJ 2021; 375 doi: (Published 30 December 2021) Cite this as: BMJ 2021;375:e058568
  1. Nestor Gahungu, cardiology registrar1 2,
  2. Robert Trueick, senior resident medical officer2,
  3. Martin Coopes, general practitioner and lecturer in general practice1,
  4. Eli Gabbay, respiratory physician and professor of medicine1 3
  1. 1School of Medicine, The University of Notre Dame Australia, Fremantle, Australia
  2. 2Department of Cardiology, Royal Perth Hospital, Perth, Australia
  3. 3Bendat Respiratory Research and Development Fund, SJOG Subiaco, Australia
  1. Correspondence to N Gahungu nestor.gahungu{at}

What you need to know

  • More than half of patients with atrial fibrillation are either asymptomatic or have mild symptoms, and none of the classic symptoms of atrial fibrillation have high diagnostic sensitivity

  • Since paroxysmal atrial fibrillation cannot be excluded by normal 12 lead ECG or short term Holter monitoring, consider prolonged monitoring in symptomatic patients with risk factors including older age, hypertension, and comorbidities

  • Opportunistic radial pulse palpation has a sensitivity of 94% for diagnosing silent atrial fibrillation in patients aged 65 and older

A 75 year old man with a history of hypertension, type 2 diabetes, obesity, gout, and stage 2 chronic kidney disease presents to the emergency department with sudden onset of diplopia, left sided hemiparesis, hemisensory loss, dysarthria, and ataxic gait. He reports a 12 month history of intermittent palpitations associated with fatigue, but previous investigations with 12 lead electrocardiograms (ECGs) and 24 hour Holter monitors have been normal. On arrival at the emergency department, he has an ECG which shows he is in sinus rhythm. Magnetic resonance imaging of his brain shows multifocal emboli involving the right middle cerebral artery territory, midbrain, and the cerebellum. Bilateral carotid doppler ultrasound shows no haemodynamically significant carotid stenoses. A review of his inpatient telemetry reveals several episodes of paroxysmal atrial fibrillation, and he is given apixaban for anticoagulation before he is discharged to a rehabilitation unit.

What is paroxysmal atrial fibrillation?

Atrial fibrillation is the most commonly encountered cardiac arrhythmia in clinical practice (box 1).7 Paroxysmal atrial fibrillation (PAF) is intermittent episodes of atrial fibrillation that terminate within seven days either spontaneously or with intervention.8 This excludes atrial fibrillation that is triggered by transient causes such as sepsis, cardiac surgery, pulmonary embolism, pericarditis, or other reversible causes.

Box 1

How common is atrial fibrillation?

  • Overall prevalence is estimated to be 2-4% in the general population, and increases with age. …

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