Dr Oliver Segal

Yes, there are three types of AF:  paroxysmal or intermittent AF, persistent AF and 
permanent AF.

• Paroxysmal or intermittent AF: AF often begins with intermittent episodes, known as ‘paroxysmal’ AF. Typically, the heart races very fast and irregularly and when this occurs it causes palpitations, breathlessness, light-headedness, tiredness or even loss of consciousness. However, up to 25% of people with paroxysmal AF won’t have any symptoms at all. 
  
  Paroxysmal AF (or PAF) is usually triggered by an extra heartbeat, called an ectopic heartbeat, from just inside one of your pulmonary veins. There are usually four pulmonary veins, which carry blood back from the lungs to the heart. Episodes can last from seconds or minutes to hours or days. 
  
  The sudden changes in and out of normal rhythm when episodes occur can be very uncomfortable and, sometimes, you’ll experience long pauses after an episode of AF abruptly stops. AF episodes are commonly triggered by alcohol (sometimes even very small amounts), caffeine, tiredness and stress.
  
  In some people, PAF can also occur for no obvious reason, even when you’re asleep.
• Persistent AF: If an AF episode lasts longer than seven days, it’s called ‘persistent’. When AF lasts this long, it means the electrical activity within the atria is sufficiently abnormal that they continue to fibrillate rather than spontaneously return to normal rhythm. 
  
  This is more likely to develop if you have a history of high blood pressure or other cardiac disease. Typically, AF starts off as paroxysmal and becomes persistent over time. However, many people are first diagnosed when their AF has already become persistent without a clear history of previous intermittent attacks.
  
  If AF is persistent, treatments designed to keep people in normal rhythm are less effective than with paroxysmal AF. The longer it has persisted, the less effective these treatments are. Although it can cause palpitations, persistent AF commonly causes tiredness, breathlessness and reduced exercise capacity. Again, up to 25% of people will experience no symptoms at all.
• Permanent AF: This is defined as AF that’s present all the time (like persistent AF) but either no efforts are being made to try to restore normal rhythm, or efforts to do that have failed. Sometimes a specialist will take this approach because the AF is not causing any symptoms, and sometimes because treatments to restore normal rhythm are deemed too risky. Sometimes the AF has been present for so long that treatments are just very unlikely to work.

Unfortunately, once AF has occurred, it will often return, although attacks can initially be separated by several years. Drugs and cardioversion can temporarily keep it at bay, however it’s only catheter ablation therapy that offers the chance of a longer-term cure.

People with AF tend to have a shorter life expectancy than those who don’t have it. It’s not the AF itself that shortens lifespan (except rarely in the case of a severe stroke), but it’s a marker of generally poorer cardiovascular health.

We now know that successful catheter ablation therapy substantially improves this prognosis, meaning people live longer after treatment, and there is also a lower risk of stroke and developing heart failure in future.

Atrial flutter is caused by an abnormal electrical signal that repeatedly travels around one of the heart's upper chambers, creating a rapid heartbeat. The most common type occurs in the right atrium, known as typical atrial flutter. This is the heart rhythm disorder that former UK Prime Minister Tony Blair had. He went on to have a successful ablation.

Electricity travels rapidly around the tricuspid valve, the valve between the right atrium and right ventricle.

There are several other types of ‘atypical’ flutter, which can occur in the left and right atrium. These are often seen after ablation within the left atrium for persistent AF, in patients with congenital heart defects, or those who have had surgery to either atrium.

Like AF, flutter also leads to stagnation of blood and therefore there’s a risk of forming blood clots that can lead to strokes.

First-line treatment for typical atrial flutter is catheter ablation, which is highly effective (>90% cure with one attempt) and carries a very low risk. Ablation is significantly better than drugs or cardioversion as a treatment for typical flutter. Ablation is quick (30-60 minutes), and it can be performed as a day case.

It’s common for patients to have both AF and atrial flutter either simultaneously or at different times. Medications can help to control both to some extent, although atrial flutter is particularly resistant to medications, but most people benefit from ablation of both arrhythmias.

Several medications can help control the symptoms of atrial fibrillation (AF), particularly by slowing your heart rate and reducing palpitations. The most commonly prescribed medications include:

• Beta-blockers, such as bisoprolol, atenolol, carvedilol and metoprolol
• Calcium channel blockers, such as verapamil and diltiazem
• Digoxin

These medications are particularly effective for people with persistent or permanent AF and are often used in combination. They may also be prescribed for those with paroxysmal AF, alongside an anti-arrhythmic medication such as flecainide to help prevent episodes of rapid heart rate.

Atrial fibrillation ablation is a treatment in which small areas of tissue are destroyed within the heart to prevent short circuits occurring. Although ablation for other arrhythmias was first performed in the early 1980s, it was only developed for AF using ‘keyhole techniques’ in 1999, and only became widespread around the world from the early 2000s.

Since then, there have been rapid and dramatic improvements in available technologies and the different techniques used with ever-increasing success rates. It is now by far the most commonly performed ablation procedure in the world. It was revolutionised by the development of pulsed field ablation (PFA) in 2025, which offers highly effective and safe ablation without needing to use thermal energy inside the heart.

Dr Segal is a respected cardiologist and electrophysiologist. He has over 25 years’ experience and has performed over 2,500 electrophysiology studies and catheter ablation procedures in that time.

His pioneering approach includes introducing pulsed field ablation to the UK private sector.  Today he uses the most advanced Medtronic Affera™ 3D mapping and ablation system to deliver safe, precise treatment to thousands of patients.