Flecainide and Propafenone can be used on a PRN basis

What is the evidence?

The ‘Pill-in-the-pocket’ management of paroxysmal atrial fibrillation (PAF) has been shown to be an effective and safe method of restoring a normal, sinus rhythm in a carefully selected group of patients. In one study this technique was successful in 80% of patients with PAF and accordingly reduced the number of hospital admissions. 


It involves taking a tablet, usually Flecainide or Propafenone, after recognizing the onset of AF. Generally this management strategy is suitable for patients with infrequent episodes of PAF, with a clear awareness of its onset and without significant underlying cardiovascular disease. The benefit of this method is the avoidance of a regular medication for a condition that may occur relatively infrequently.


 Our local policy

  1. Confirm the onset of AF with a pulse-check.
  2. If clinically unwell, with symptoms of breathlessness, chest pain or loss of consciousness for example, the patient should attend hospital immediately.
  3. Otherwise wait for 30 minutes in case the heart rhythm corrects spontaneously.
  4. If this does not occur, take a single dose of Flecainide (300mg if weight > 70kg, 200mg if weight < 70kg) or Propafenone (600mg if weight > 70kg, 450mg if weight < 70kg).
  5. Avoid any strenuous activity until reversion to normal rhythm.
  6. Again, if you have symptoms of breathlessness, chest pain or loss of consciousness for example, you should attend hospital immediately.
  7. If you have ongoing symptoms after 8 hours we would advise hospital attendance for further investigation and consideration of an electrical cardioversion.


Rarely this drug can itself precipitate a different type of arrhythmia. We therefore advise that each patient has an initial ‘test-dose’ of Flecainide or Propafenon in hospital with cardiac monitoring prior to adopting this strategy in the community.

Should the frequency of PAF episodes occur more than on a monthly basis then we would advise discontinuation of this regime and commencement of regular medication alongside consideration of anticoagulation.

Related links and Stories

Pill in the pocket for patients
Pill in the Pocket from Professor Camm and the AFA
AFA Atrial Fibrillation fact sheet
Using Novel Anticoagulant Drugs as required



Written by

Cardiology Research Fellow working with The University of Surrey and The Royal Surrey County Hospital funded by HASTE.


You must be logged in to leave a reply. Login »