A 72-year-old woman is found to have an irregular pulse rate at a routine clinic visit. She is experiencing no new symptoms at rest or on exertion. Her past medical history includes hypertension, osteoarthritis, and dyslipidemia.On physical examination, the blood pressure is 135/85 mm Hg, heart rate is approximately 72/min and irregular. The heart sounds reveal an irregular S1 and normal S2 with no audible murmurs. The jugular venous pressure is normal and the lungs are clear. On the ECG, there are no P waves and an irregular RR interval at a rate of 70/min. (See Figure below) On her previous ECG from 4 years ago she was in sinus rhythm. Which of the following is the most appropriate next step in management?
A discussion about the risks and benefits of anticoagulation is the most appropriate next management step for this patient, in addition to investigating why she has developed atrial fibrillation. Since the duration of atrial fibrillation is not known, it is presumed to be chronic. There is an increased risk of cardioembolic events if restoration of sinus rhythm is attempted before anticoagulating the patient for 3-4 weeks so cardioversion and antiarrhythmic therapy are not appropriate choices. Aspirin is only modestly effective in reducing cardioembolic events and not the first choice. Beta-blockers are not indicated since the rate is controlled (indicating she has underlying AV nodal disease).
cardioversion
antiarrhythmic therapy
beta-blocker
anticoagulation
C.V.S.